Child's details
If contact details are incorrectly input where mandatory the referral cannot be processed
Child's name:*
Parent/carer's name:*
DOB:*
Sex:*
Male
Female
NHS no.:*
Religion:
Child's current address:*
Postcode:*
Tel no:*
Email address:*
Skype ID:
Ethnicity:
Next of kin:
GP name:*
Consultant:
Interpreter required? (If yes, state language)
Consent for contact by email:*
Referral discussed with parents:*
Do parents consent to referral?*
Patient consented to information sharing?*
Please tick to confirm that the parent/carer consents to their child receiving assessments and interventions, as is appropriate to this referral:*
The parent/carer should be aware that if at any point they do not want further treatment or interventions, they must inform their clinician:*
Name of school/nursery:
Diagnosis/Medical History/Medications/Allergies:
Referrer name:*
Referrer email:*
Referrer contact details:*
Referrer job title:*
Referring from:
Acute
Care Home
GP Practice
Hospice
Local Authority
School
Self Referral
NHS no.:*
Religion:
Child's current address:*
Postcode:*
Tel no:*
Email address:*
Skype ID:
Ethnicity:
Next of kin:
GP name:*
Consultant:
Interpreter required? (If yes, state language)
Consent for contact by email:*
Referral discussed with parents:*
Do parents consent to referral?*
Patient consented to information sharing?*
Please tick to confirm that the parent/carer consents to their child receiving assessments and interventions, as is appropriate to this referral:*
The parent/carer should be aware that if at any point they do not want further treatment or interventions, they must inform their clinician:*
Name of school/nursery:
Diagnosis/Medical History/Medications/Allergies:
Referrer name:*
Referrer email:*
Referrer contact details:*
Referrer job title:*
Referring from:
Acute
Care Home
GP Practice
Hospice
Local Authority
School
Self Referral
Detail
Fluids - Type and Amount
Frequency of voids/wetting?
Frequency of any soiling?
Does the child experience any pain on bowel movement?
Does the child ask to go to the toilet for a wee or poo?
Where does the child normally open their bowels?
Any continence products used recently?
Parent's perception of continence problem?
Child's perception of continence problem?
If you do not receive an email acknowledgement your referral has not been submitted. Please check that all details are correct, mandatory fields completed and re-submit.
