Child's Details

If contact details are incorrectly input where mandatory the referral cannot be processed

Referrer type *

Education/School

Health (GPs, consultants or health professionals)

Schools (SENCO) are now able to refer directly into the service. Before a referral can be accepted a proforma (for the relevant age of the child) will need to be completed BEFORE any referral can be considered.

On receiving the completed proforma if the results indicate a global developmental delay of 2 years or more, they will not meet the criteria for a detailed assessment, but the appropriate package of support will be sent out to both school and parents.

Step one

Download and complete relevant proforma:

OT Screening proforma age pre-5

OT Screening proforma age 4-6

OT Screening proforma age 7+

Step two

Upload proforma below

Please attach completed OT Screening proforma here * Upload file

Childs Name *

Parents/Carers Name *

Date of Birth *

Sex *

Child's Current Address *

Postcode *

Telephone Number *

Overseas visitor? *

Yes

GP Name *

Consultant *

Please state all the languages spoken at home *

Is an interpreter needed for child/carer/parent? *

Yes

If Yes, for what? *

Are there any communication needs for this child or their parent/carer? For example, related to learning disabilities or autism or due to impaired sight/ hearing or any other reason/s. *

Yes

What might be helpful when communicating with this child or their parent/carer? *

Do the parents consent to this referral? *

Yes

Without consent the referral will not be accepted

Consent gained for the child’s electronic medical record to be shared *

Yes

Without access to the child’s medical record, we will be extremely limited in what care we can offer and this may affect the child's progress

Name of School/Nursery *

EHC Plan or Statement *

Yes

Diagnosis/Medical History *

Referrer Name *

Referrer Email *

Referrer Contact Number *

Referring from *

Reason For Referral

On the next pages, please state why you are referring this child by identifying your concerns in any of the following areas:

Muscles

Increased Tone *

Upper Limbs Trunk

Lower Limbs N/A

Decreased Tone *

Upper Limbs Trunk

Lower Limbs N/A

Fluctuating Tone *

Upper Limbs Trunk

Lower Limbs N/A

Muscle Weakness *

Upper Limbs Trunk

Lower Limbs N/A

Comments

Joints/Bones

Hypermobility *

Upper Limbs Hips

Lower Limbs N/A

Contractures *

Upper Limbs Hips

Lower Limbs N/A

Deformities *

Upper Limbs Spine N/A

Lower Limbs Hips

Comments

Gross Motor

Any difficulties with the following: *

Rolling Standing Balance co-ordinated movements

Sitting Mobility N/A

Comments

Fine Motor

Any difficulties with the following: *

Hand function/ grip affecting independence Writing skills

Bilateral tasks N/A

Comments

Activities of Daily Living

Any difficulty with any of the following: *

Feeding Dressing N/A

Toileting Bathing

Comments

Other

Other concerns/relevant information?

Children's Occupational Therapy NORTH ONLY