Form Page | Gloucestershire Health and Care NHS Foundation Trust

Child's Details

Name *

Gender *

NHS Number *

Spoken language *

Ethnicity *

Interpreter needed? *

If yes, please describe in more detail. *

Religion *

Religion (other)

Home/Carer Details

Name of child's main carer *

Relationship with child *

Please upload the Delegation of Authority or other documentation which confirms that you have legal authority or parental responsibility for the child

Max. file size: 64 MB.

If you are unable to upload the required documentation, please mail it to ChildrenOT.Referrals@ghc.nhs.uk

Relationship (other)

Home Phone Number

Work Phone Number

Mobile Phone Number

Email *

The parent/carer email address is required for the initial contact/assessment processes. If incorrect details are provided there could be a delay in our service provision.

If a parent\carer email address is not available please provide an explanation below

Does this child or the child's family pose a risk to a lone worker?* *

Name of person with parental responsibility *

Address if different from main carer

Home situation *

Other relevant information (cultural, social, home situation)

Consent

Have you gained parental consent for this Occupational Therapy referral *

Parental consent to contact and share information with involved professionals

Care Plans/SENCO

Educational setting *

School Year *

Is the child on a child protection plan?

Is the child a child in care? *

Please ring 0300 421 6988, our normal working hours are Monday to Friday 8.30 to 16.30, outside these hours you should leave a voicemail message

What type of support does your child receive?

Caseworker name

Caseworker Contact Number

SenCo name

SenCo Contact Details

Concerns

Parent/carers main concerns *

Child's main concerns *

Diagnosis or primary area of difficulty *

Professionals involved

Other professionals involved (details)

Referral Details

Please select date the surgery took place

Please state the reason for referral which relates to the above ticked box(es) *

We need to know details of the difficulty ie is not able to focus attention on work set during classroom tasks without the support of an adult, is unable to tolerate having their teeth cleaned/washing their hands

What interventions (related to this issue) have been tried or are currently in place *

If previously seen by Occupational Therapy, when was the last contact?

Referrals from education professionals for children with identified issues above which are related to coordination difficulties will need to show evidence of four terms of a movement programme. Evidence provided?

If no the referral will be returned and can be re-submitted when the evidence is available

What is the desired outcome from an OT assessment/intervention? *

Are there any safety issues/risks for the child or others (arising from child's needs)? Please specify

Referrer Details

Referrer's Name *

Referrer profession and organisation (or enter 'Parent/Carer/Guardian' as applicable if referrer is not a healthcare professional) *

Referrer's Email *

Referrer's Telephone *

Please call us

Please ring 0300 421 6988, our normal working hours are Monday to Friday 8.30 to 16.30, outside these hours you should leave a voicemail message

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