SPECIALIST DISABILITY SERVICE
REFERRAL FORM
Oxford Centre for Enablement, Windmill Road, Headington, Oxford, OX3 7HE
T: 01865 227 447 | F: 01865 227 294 | specialist.disabilityservice@nhs.net
PATIENT DETAILS
Full name:
Title:
Address:
Telephone no:
Mobile no:
Postcode:
NHS no:
Email:
Date of birth:
Diagnoses:
Height:
Weight:
Other relevant medical details (e.g.
planned surgery, tissue status):
REFERRAL DETAILS
Please select the area(s) of the service for which a referral is being made*:
Wheelchair seating:
Static seating:
Bespoke toilet seat / shower chair:
Bed positioning:
Mobile arm support:
Pressure mapping:
Other (please specify):
Computer access:
Environmental control:
AAC (also complete communication aid referral form)**:
Complex wheelchair controls:
Integrated electronic assistive technology:
Parent with a disability:
Detailed reason for
referral, including
aims of intervention
(please provide
sufficient information
to allow appropriate
prioritisation):
Other relevant
information:
* Please note that a funding source for equipment may need to be identified.
** Referrals only accepted from a Speech and Language Therapist, unless prior agreement exists.
Please continue overleaf
Details of home/day care
arrangements:
Level of mobility
(include type of equipment used)
Indoors:
Outdoors:
Method of transfer
(include type of equipment used):
Outline dependency
(in terms of activities of daily living):
Ability to communicate:
Indicate means of transport to appointment:
If a home visit is required,
please provide:
Own/home vehicle
Ambulance
a) A brief rationale
b) Access details
GP (name and initial)*:
Telephone no:
Address:
Postcode:
* Essential information to identify CCG before referral is processed
Other professionals involved (as applicable):
Name and profession
Telephone no.
Email
Involvement
REFERRER DETAILS
Referred by:
Job title:
Address:
Tel no:
Mobile no:
Postcode:
Email:
You should receive correspondence confirming receipt of this referral within two weeks of submission. If this is not the case
please contact the administrator using the details at the top of this form.
We will keep your email address on file and may send you information about the service from time to time. If you would rather
not receive such emails, please tick the box:
Signed:
Date of referral:
Where did you hear about SDS? Previously referred / internet / word of mouth / mail shot
Document name
SDS referral form
Issue Date/Author
05/2014 DL
Reviewed
02/2015 NR
Version
1.1