Office use only:Date received:-
Paediatric Therapies Services Referral Form
Surname:
Forename/s
Date of birth:
NHS No:
Interpreter
needed?
Yes
No
Please circle which service(s) you are referring to:
Occupational Therapy
Physiotherapy
Speech & Language Therapy
Parental/Family Details
Name of parent/carer:
Relationship to child:
Telephone Numbers:
Home:
Mobile:
Work:
Address:
Postcode:
Medical Details
GP Surgery:
Relevant medical history including diagnosis:
(e.g. premature, complications at birth, delayed
milestones, hospitalisations, dates of any stays in
hospital, ear infections)
Is a medical diagnosis being considered?
Yes
No
(please circle)
Does the child have a Child Protection Plan?
Yes
No
(please circle)
Is the child a looked after child?
Yes
No
(please circle)
Has this child been referred for a MultiDisciplinary Assessment (MDA) or Child
Assessment service (CAS)?
Yes
No
(please circle)
Is the child showing a delay across all areas of
development/function?
Yes
No
(please circle)
If yes, please state:
Involvement with Other Agencies
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Is this child known to any other agency?
Yes
No
(please circle)
If yes please identify which service? ………………..…………………………………………….
Audiology / CAMHS/ Education Outreach Services e.g. PSSS, LLS, Portage, EP / Orthoptist /
Orthotic / ENT / HV / Paediatrician / Specialist Nurse for LD / Podiatry/Social Services
Education Details (if attending)
Name of School/Early Years setting:
*When does child attend? (if not full-time)
(education only)
Year Group:
*Start Date:
*SENCO/Key Worker contact name and number (education only):
*Stage of Code of Practice (education only):
Action / Action Plus / Gathering Evidence for Statutory Assessment/
Statutory assessment/
Statement
*If referring to OT (education only):
Has the OT resource pack been completed?
Yes
No
(please circle)
Reason for Referral (as applicable) - Please describe how the child’s difficulties are affecting their
everyday life? What support are the parents seeking?
……………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………
Please circle which of the following areas you are concerned about:Movement and mobility: sitting, standing, walking, balance, co-ordination, seeks/avoids movement
which affects functional activities, need for specialist equipment
Pain: loss of function, decreased range of movement, loss of skills, muscle weakness, asymmetry
Self-care skills: dressing, bathing, toileting, feeding, organising self, independence, excessive
sensitivity and discomfort during self-care skills, need for specialist equipment.
Eating and drinking: swallowing difficulties, choking, coughing while eating
Communication: speech sounds, understanding instructions, vocabulary, fluency, spoken language,
voice
School tasks: writing, using scissors, participation in PE, maintaining attention
Interaction and Play skills: interest in toys, turn taking, playing with peers, role play, imagination,
friendships,
Behaviour: interests, response to changes in routine, aggression, high/low activity level which
affects taking part in functional activities, impulsivity, mood, focus on toys/play/school work,
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Referrer Details
Name of referrer……………………..…………………Profession………………………………………….
(print name)
(e.g. Hosp/GP/HV/School etc)
Signature:……………………………………………………………………………………………………….
Address………………………………………………………………………………………………………….
………………………………………………………………………………………………………………….
Tel No:…………………………………………………. Date of referral:…………………………………..
Consent for Referral
Please tick to confirm you have gained consent from parents/carers for this referral
For school-based initial assessment only (education only):Please tick to confirm a ‘school-based initial assessment consent’ form has
been enclosed with this referral.
We are unable to accept this referral without consent from parents/carers.
Health Professionals for school-aged children:- Please note we may need to gather additional
information from the educational setting before this referral can be accepted. Please complete the
referral as fully as you can.
Education Professionals:- Any incomplete forms may be returned.
Please return to:East Locality
– Paediatric Speech and Language Therapy
Community Children’s Centre, East Surrey Hospital, Canada Avenue, Redhill RH1 5RX
Tel: 01737 768 511 ext. 6090 (SLT)
-Paediatric Occupational/Physiotherapy
Therapies Department, East Surrey Hospital, Canada Avenue, Redhill RH1 5RX
/ ext. 6138 (OT) Tel: 01737 231 628 (PT)
North West Locality
– Paediatric Therapies,
The White House, Addlestone Health Centre site, Crouch Oak Lane, Addlestone KT15 2AN
Tel: 01932 826 500
South West Locality
– Paediatric Occupational Therapy/Physiotherapy
The Jarvis Centre, 60 Stoughton Road, Guildford GU1 1LJ
Tel: 01483 783148
- Paediatric Speech and Language Therapy
Buryfield’s Clinic, 61 Lawn Road, Guildford, GU2 4AX
Tel 01483 783 315
(East & South West Locality - please send a separate copy to each address if referring to SLT and OT/PT)
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