GSTT Community Services
Lambeth Referral Form
Use this form for:
Specialist Children’s Services (Community
Paediatricians, Physiotherapy, Occupational Therapy, Speech and Language
Therapy and Specialist Health Outreach Team)
Please give as much information as possible. This will help us to process
your referral quickly and appropriately.
Please indicate (x) the service(s) you think this child needs:
Community Paediatrician
Speech and Language Therapy
Physiotherapy
Outreach worker complex needs 0-5
Occupational Therapy
Continuing Care Nurse
Referrals are reviewed by clinicians and an assessment plan is agreed. Where relevant this
may be in a uni-disciplinary clinic, a multi-disciplinary clinic or a joint assessment depending on
the needs of the child.
To ensure the best possible assessment for the child, we may contact colleagues in other parts
of the health service as well as professionals in Social Care, Education and other relevant
agencies to seek their input. Please check this box to indicate that this has been
explained to the parent / carer
A referral acknowledgment letter will be sent describing the intended assessment process. If
this has not been received within 3 weeks of sending the referral please contact the Customer
Service Centre on 020 3049 4005.
NHS No _________________________________________________________________________________
Title ____________________ Family Name (surname) ___________________________________
Given Name (First Name) _____________________________________________________________
Gender _________________________________ D.O.B. _____________________________(dd/mm/yyyy)
Religion ___________________________ Is the patient housebound? ____________________
Ethnicity (please check as appropriate)
WHITE
British
Irish
Any other white background
MIXED
White and Black Caribbean
White and Black African
White and Asian
Any other mixed background
ASIAN OR ASIAN
BRITISH
Indian
Pakistani
Bangladeshi
Any other Asian
background
BLACK OR BLACK
BRITISH
Caribbean
African
Any other black
background
OTHER ETHNIC
GROUPS
Chinese
Any other ethnic group
Not Stated
Patient/Client Address ________________________________________________________________
___________________________________________________________________________________________
___________________________________________
Postcode ___________________________________
Landline _______________________________ Mobile _______________________________________
Name of GP ___________________________ GP Surgery ___________________________________
School / Nursery attended ____________________________________________________________
___________________________________________________________________________________________
Name of care giver ____________________________________________________________________
Relationship to child __________________________________________________________________
Contact Details (if different from above) ____________________________________________
___________________________________________________________________________________________
Is an Interpreter required __________________ Which language? _____________________
If patient is currently in hospital,
what is the anticipated discharge date? ___________________________________________
Current Medication (attach list if available) ________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Are there any safeguarding issues? _________________________________________________
___________________________________________________________________________________________
Social Information
Is this child a ‘looked after child’?
Does the child have a child protection plan?
Does the child have a child in need plan?
Does the child have a statement of Special Education Needs
Does the family have an allocated Social worker?
If yes please give details:
Yes
Yes
Yes
Yes
No
No
No
No

Yes
No

Name __________________________________________ Contact Number __________________________
Email _____________________________________________________________________________________
Address ___________________________________________________________________________________
___________________________________________________________________________________________
If there is likely to be a problem with attendance,
please indicate any support that might be helpful. ____________________________________________
___________________________________________________________________________________________
Additional / Medical Information
Any relevant history e.g pregnancy and birth, family health and social history, medical
information etc.
___________________________________________________________________________________________
___________________________________________________________________________________________
Past Medical History __________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Other professionals involved__________________________________________________________
___________________________________________________________________________________________
Reason for Referral ____________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Please describe how the child’s difficulties are affecting their everyday life.
Movement and mobility: sitting, standing, walking, balance and co-ordination.
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Self-care skills: dressing, bathing, toileting, feeding, organising self, independence.
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Communication: speech sounds, understanding instructions, vocabulary, fluency, non-verbal.
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
School tasks: writing, using scissors, participation in PE, maintaining attention.
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Play skills: interest in toys, turn taking, playing with peers, role play and imagination.
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Behaviour: friendships, interests, changes in routine, aggression, activity level, impulsivity,
mood, focus on toys/play/school work.
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Has this referral been discussed
and agreed with the Patient/Client _________________________________________________
or Carer? ______________________________________________________
Name of Referrer ______________________________________________________________________
Designation ____________________________________________________________________________
Address _________________________________________________________________________________
___________________________________________________
Postcode ___________________________
Email ____________________________________________________________________________________
Landline ___________________________________ Mobile ____________________________________
Signed__________________________________________________ Date ______________________
Once completed please send this form, together with any relevant reports or
letters to:
Email: GST-TR.referralschildrencustomerservice@nhs.net
Please ensure it is sent via a secure email connection eg. nhs.net account. Otherwise
please send hard copy or fax to:
Referrals
Children’s Customer Service Centre
Mary Sheridan Centre
5 Dugard Way
Kennington
SE11 4TH
Phone
Fax
020 3049 4005
020 3049 4015