CHILDREN’S COMMUNITY OCCUPATIONAL THERAPY – REFERRALS PLEASE COMPLETE AS

Name:

Date of birth:

Address with Post code:

Telephone number:

Parent/ Carer’s name(s):

Parent/ Carer’s contact details – if different:

NHS number:

Preschool/ School/ College:

Preschool/ School/ College contact details:

Consent gained – yes/ no (delete as appropriate)

Parent signature date

Diagnosis (if appropriate):

Other professionals involved

S&LT Social worker

Physio SEND worker

Paediatrician

Other

Referrer information

Name

Signature Date

Contact details

Reason for referral

Please explain the impact of this problem on the child’s daily life.

Please outline any strategies that have been used to help the child and whether these have been successful.

Drawing / writing/ scissors

Walking/running/hopping/riding a bike

Ball skills, throwing and catching

Attention/ Concentration

Dressing, including fastenings

Toileting

Feeding/ using cutlery

Play skills

Interests / preferred activities

Additional information