Step 1 of 5 20% I have read and understand the referral information above * REQUIRED I agree Child's DetailsName First Last Date of Birth:DayDay12345678910111213141516171819202122232425262728293031MonthMonth123456789101112YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Address Address Line 1 Address Line 2 City Postal code NHS NumberGender assigned at birth Male Female Identifies as:Preferred pronounsPlease SelectShe / herHe / himThem / theyEthnicity * REQUIREDEnglish/Welsh/Scottish/Northern Irish/BritishIrishGypsy or Irish TravellerAny other White background, please describeWhite and Black CaribbeanWhite and Black AfricanWhite and AsianAny other Mixed/Multiple ethnic background, please describeIndianPakistaniBangladeshiChineseAny other Asian background, please describeAfricanCaribbeanAny other Black/African/Caribbean background, please describeArabAny other ethnic group, please describePrefer not to discloseMain language spoken * REQUIREDIs an interpreter needed? * REQUIRED Yes No Name of GP practiceName of GPName of school / nurseryDoes the child have accessibility needs * REQUIRED Yes No Please describe any accessibility needs the child hasIs this young person on the child protection register? Yes No Is this young person subject to a child in need plan? Yes No Is this young person on the graduated pathway? No My Plan My Plan+ EHCP In progress Referrer's DetailsName First Last What is your relationship to child---please select one---ParentGuardianFoster carerSocial workerTeacherConsultantOtherIf other, please give more detailsContact number * REQUIREDEmail * REQUIRED Parent / Guardian detailsFirst parent / Guardian name First Last Relationship to child---please select one---ParentGuardianSecond parent / Guardian name First Last Relationship to child---please select one---ParentGuardianDoes the child live at the same address? * REQUIRED yes No Address of parent / Guardian Street Address Address Line 2 City Postal code Please note if your child has a delegation of authority in place, we will require a copy of this.Max. file size: 64 MB. Has the parent / guardian given their consent for this referral? * REQUIRED Yes No **Unfortunately, you cannot continue with this referral until you have consent from the parent or legal guardian** ReferralWhat is this referral in relation to? * REQUIRED Option 1 - Under 5 year old Option 2 - School aged child/ young person Under 5 year oldReason for this referral. Please describe the problemDevelopmental HistoryIf appropriate, please provide details on the child’s development including age when skills were achieved e.g. rolling, sitting, crawling and walking etc.Birth HistoryPlease provide as much detail as possible with regards to the birth history including prematurity, birth weight, any newborn concerns, admission to the neonatal unit. Medical History (please include all childhood illnesses, surgeries, allergies and interventions)Current MedicationWhat would you like to achieve by seeing a physiotherapist?Has the child displayed any loss in physical skills? Yes No Not appliable Please detail the physical skills the child has lostCan the child accept weight through legs in supported standing by 12 months old Yes No Not appliable Please detail more about the child's inability to accept weight through legsHas the child displayed signs of pain / discomfort when changing a nappy Yes No Not appliable Please detail the pain or discomfort the child is experiencing during a nappy changeDoes the child use one side of the body more than the other Yes No Not appliable Please detail more about the child's need to use of one side of their body more than the otherHow do these problems impact the child's functional abilities and daily life?Have you tried anything to help with these problems?Has the child seen any other health care professionals regarding these problems?For example: GP, Podiatry, Occupational Therapy, Orthopaedics. School aged child/ young personWhat part/ s of the body is this referral relating to? Rheumatology Neuromuscular condition Neurological condition Neck Back Elbow Wrist Shoulder Knee Hip Ankle / foot Other Please describe in as much detail as possible, why you are making this referral.Medical historyPlease include all childhood illnesses, surgeries, allergies and interventions.Is the child taking any regular medication? Yes No Please give more details on medication historyWe cannot accept referral for hand pain or hand trauma. Please follow this link to thehand therapy service.We cannot accept referral for problems relating to hand function. Please follow this link to thechildren’s occupational therapy service.We cannot accept referral for foot and ankle pain (excluding trauma). Please follow this link to the podiatry service.How long has this problem been going on for? Less than 6 weeks 6 - 18 weeks More than 18 weeks How would you describe the current problem? Getting worse Getting better Staying the same Is the problem a result of injury or trauma? Yes No Not applicable Please describe in more detail the injury or trauma.Has the child been experiencing any of these symptoms? Unexplained weight loss Pins and needles Numbness Changes in bladder / bowel function Night pains Morning stiffness lasting more than 30 minutes Constant unrelenting pain Sudden deterioration to walking / mobility Please describe in more detail these symptoms including onset and body location.How do these problems impact the child's functional abilities and daily life?Have you tried anything to help with these problems?Has the child seen any other health care professionals regarding these problems?For example: GP, Podiatry, Occupational Therapy, Orthopaedics. What would you like to achieve from seeing the physiotherapy service?Please describe below if any of the following investigations have taken place: X-ray, MRI, ultrasound and / or blood test **Thank you for completing this referral form. **CAPTCHA