COMMUNITY OCCUPATIONAL THERAPY REFERRAL
OT R1
Office use only
Date Received
Client Status
P
R
Prioritiser’s signature:
Staff Grade (to action)
Clinic
PLEASE COMPLETE FULLY IN ORDER TO PROCESS YOUR REFERRAL
REFERRAL WILL BE RETURNED IF MANDATORY FIELDS (I.E. THOSE IN BOLD PRINT AND
UNDERLINED) ARE INCOMPLETE
Surname:
Forename:
Mr / Mrs / Miss / Ms
Address:
Post Code:
Tel No:
No phone

Previous Address:
Date of birth:
H&C No. (HSC Staff only):
GP Name:
Address:
Consultant Name:
Hospital:
Dept:
Other Professions Involved (specify)
Care Managed
Yes:  No: 
Primary Diagnosis:
Relevant Medical History (including psychiatric history)
Please identify problems experienced by client and reason for referral
June 2011


HOME SITUATION: (PLEASE TICK)


Lives alone

Lives with other elderly person(s)

Lives with other disabled person(s)

Lives with able-bodied family members

Name Of Main Carer:
Tel:
Next of kin:
Tel:
House Type




NIHE
Flat Ground
Floor
Flat 1st Floor




 Privately Owned
Housing
Privately Rented
Association
Bedroom  
Bungalow
Bathroom  
Two Storey
Toilet
 
Flat Other
Floor
Are there any potential risks to staff visiting?
Yes specify__________________________
No
CAN CLIENT ATTEND ASSESSMENT CLINIC?
Yes:

No: 
*
* If no please state reason.__________________________________________
Clients permission to contact GP (if necessary)
Yes:

No:

Referred by (print) ______________________ (signed) ______________________
Designation
Address
Does Client Consent to Referral
Tel. No.
Yes  No 
Date
June 2011
Community Occupational Therapy Department, Disability Resource Centre, Downshire Hospital
DOWNPATRICK BT30 6RA, Tel: 02844 513810 Fax: 028 90411898
June 2011