Paediatric Occupational Therapy Self Referral Form

Name

This field is for validation purposes and should be left unchanged.

Paediatric Occupational Therapy Self Referral Form

Children and young people can be seen at any age from birth up until they leave school.

A GP or Health Visitor referral is no longer needed to access Children’s (Paediatric) Occupational Therapy. Instead, a parent or legal guardian with parental responsibilities can fill in this Self Referral Form. If the young person is 16 years or over they can refer themselves.

Why refer to Occupational Therapy?

Occupational Therapy aims to enable the child or young person to be as independent as possible. A referral to OT would be appropriate if there is a specific difficulty which is stopping the child/young person from taking part in activities of everyday life. This may involve playing; self care and participating in activities at school, home and in the wider community.

The OT will help identify and problem solve practical difficulties providing advice and strategies for those supporting the child/young person. Areas in which we can help are coordination difficulties with everyday tasks, independence skills (dressing, toileting, meal times, personal care, getting about), play skills and adapting the environment (specialist equipment and adaptations).

Child's name(Required)

First Middle Last

Date of birth(Required)

School and Class(Required)

Name of parent / guardian(Required)

First Middle Last

Home phone

Mobile phone

Can a message be left at these numbers?(Required)

Yes

Home address

Street Address Address Line 2 City County Post code

GP name and address

Street Address Address Line 2 City County Post code

Do you require an interpreter?(Required)

Yes

Which language do you require?

Past Medical History

Birth history

Please enter any relevant information

Family medical history

Please enter any relevant information

Medication / allergies

Please enter any relevant information

Investigation – previous / pending

Please enter any relevant information

Phone number for a clinician to contact you

Please ensure that your phone numbers are current and accessible.

Please provide information about why you would like a Paediatric Occupational Therapy assessment and how the problem is affecting your child in their daily life.(Required)

Have you consulted your GP about the problem?(Required)

Yes

Do you think your child has delay in their movement development?(Required)

Yes

Is this difficulty affecting their school performance?(Required)

Yes

Are they able to participate in all relevant activities?(Required)

Yes

Is this a new problem?(Required)

Yes

Have they had any OT input in the past?(Required)

Yes

How long has your child had this problem?

Privacy Policy

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.

Thank you for completing the form. After you click submit this will be sent to the surgery.

On receipt of the referral the OT team will look at your form and decide if the referral is appropriate for our service, a member of the team will contact you.