Form Page | Gloucestershire Health and Care NHS Foundation Trust

Child's details

Child's Name *

Child's Address *

Address Line 1 Address Line 2 City Post code

Child's Date of Birth *

Child's NHS Number *

Child School\Setting *

Please input name of school or any other educational setting the child attends

Contact Details

Name of Parent/carer/guardian *

Parent/carer/guardian Email Address *

Contact Number *

Alternative Contact Number

1. Occupational Therapy

Is the child already known to the service? *

Yes
No

Please record details

Does your child have significant difficulty (and does not already have supporting equipment or strategies to practice) with self-care skills required to access to education e.g. changing for PE, getting on and off the toilet, personal hygiene, eating difficulties -using a knife and fork, opening packaging? *

Yes
No

Please record details

Does your child have any significant difficulties using tools in school, scissors, pen, pencil, ruler, cookery and design and technology equipment? *

Yes
No

Please record details

Does your child have any difficulty accessing the physical school environment? *

Yes
No

Please record details

Does your child have any significant difficulties with any functional activities within the school day; excluding behavioural concerns not related to health concerns/diagnosis/disability/, or any mental health issues? *

Yes
No

Please record details

Are you requesting a referral to Occupational Therapy due to the above identified needs? *

Yes
No
Not applicable - no need

If you are requesting a referral to Occupational Therapy due to the above identified needs, do you consent to this referral being made? *

Yes
No
Not applicable - no need

2. Physiotherapy

Is the child already known to the service? *

Yes
No

Please record details

Does your child have a mobility difficulty which impacts upon their ability to access school? *

Yes
No

If Yes, please record details

Can they walk independently inside at school? *

Yes
No

Please record details

Can they walk independently outside at school? *

Yes
No

Please record details

Can they climb and descend the stairs, this can be with the use of a handrail at school? *

Yes
No

If No, please record details

Can they get up from a seated position on the floor unaided at school? *

Yes
No

If No, please record details

Are you requesting a referral to Physiotherapy due to the above identified needs? *

Yes
No
Not applicable - no need

If you are requesting a referral to Physiotherapy due to the above identified needs, do you consent to this referral being made? *

Yes
No
Not applicable - no need

3. Speech and Language

Is the child already known to the service? *

Yes
No

If Yes, please record details

Is your child’s speech difficult to understand? Does this make communicating at school difficult? *

Yes
No

If Yes, please record details

Does your child stammer (e.g. repeating sounds, getting stuck on words, saying words again and again)? Does this make communicating at school difficult? *

Yes
No

If Yes, please record details

Do teachers say your child has problems following instructions and/or listening? *

Yes
No

If Yes, please record details

Does your child find it hard to tell teachers and friends what they want, what they’ve done, what they think or what they know? *

Yes
No

If Yes, please record details

Are you requesting a referral to Speech and Language Therapy due to the above identified needs? *

Yes
No
Not applicable - no need

If you are requesting a referral to Speech and Language Therapy due to the above identified needs, do you consent to this referral being made? *

Yes
No
Not applicable - no need

CAPTCHA