Children's Occupational Therapy Referral Form


Referrals are accepted for Occupational Therapy Assessment from professionals where children have significant difficulties impacting on their participation in activities of daily living which are not in line with their developmental age.

Appropriate intervention in the form of education and empowerment of those nearest to the child is evidenced as best practice. Further assessment may be offered based on needs to increase independence and/or support parents/ carers in assisting their child in activities of daily living.

Referrals are also accepted from parents/carers for an Occupational Therapy assessment of need for children with a permanent and substantial disability.

The guide to referrers can be opened here:

Child's Details

Name*
Please input child's name

Gender*
Please enter child's gender

NHS Number*
Please enter child's NHS number

DOB*
/ / Please enter child's date of birth

Language*
Please enter child's main language

Ethnicity*

Ethnicity (other)
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Address Line 1*
Please enter first line of child's address

Address Line 2
Please enter second line of child's address

Town*
Please enter town child currently resides in

Postcode*
Please enter child's postcode

Interpreter needed?*
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Religion*
Please enter child's religion

Religion (other)
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Contact Details

Home Phone
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Mobile Phone
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Work Phone
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Email*
Please input valid email address

Preferred method of contact*
Please select preferred method of contact

Home/Carer Details

Name of child's main carer*
Please input name of child's main carer

Relationship with child*
Please enter relationship of main carer to child

Relationship (other)
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Does this child or the child's family pose a risk to a lone worker?*
Please enter lone worker risk

Name of person with parental responsibility*
Please input name of person with parental responsibility

Address if different from main carer
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Home situation*
Please enter child's home situation

Other relevant information (cultural, social, home situation)
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Have you gained parental consent for Occupational Therapy referral*
Please select option for parental consent

Parental consent to contact and share information with involved professionals*
Please select parental consent to share option

Care Plans/SENCO

Educational setting*
Please input an educational setting

School Year*
Please input a school year

Is the child on a child protection plan?*
Please select a child protection plan option

Is the child a child in care?*
Please select a child in care option

Is this an urgent referral due to discharge from hospital?*
Please select an urgent referral option

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
Does your child receive any support in relation to a Special Educational Need or Disability (SEND)?*
Please select an EHCP option

What type of support does your child receive?
Please select type of support received

Caseworker name
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SenCo name
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Caseworker Contact Number
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SenCo Contact Details
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Concerns

Parent/carers main concerns*
Please input parent/carer's main concerns

Child's main concerns*
Please input child's main concerns

Diagnosis or primary area of difficulty*
Please input diagnosis or primary area of difficulty

Professionals involved

Other professionals involved

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Other professionals involved (details)
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Referral Details

What are the child's functional difficulties?
Please tick the relevant box(es)
*

Please select a functional difficulty from the checkboxes

Functional difficulties in the school environment

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Please select date the surgery took place
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Please state the reason for referral which relates to the above ticked box(es)*
Please input reason for referral

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*
Please input interventions tried/in place

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

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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?


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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?*
Please input desired outcome

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

Name*
Please input referrer name

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

Telephone*
Please input referrer contact number

Email*
Please input valid referrer email address

FAQs

Q. I cannot submit the referral form.
A. Go back and check the form as you may not have completed all the mandatory sections.

Q. The information I have does not fit in the sections or on the form.
A. Check the referral criteria as you may not be referring to the appropriate service or you may need to gather more information before you make the referral.

Q. There is not a section related to Sensory Processing. How can I make a referral for this type of assessment?
A. The Gloucestershire Children’s Occupational Therapy Service offer Occupational Therapy Assessments around a child’s functional needs within their everyday activities. Children’s Occupational Therapists are trained to look at a child/young person in their environment and the everyday tasks they need and want to do. An Occupational Therapist has specialist skills in task analysis and in looking at the person holistically by considering how underlying skills such as motor and visual perceptual skills, medical conditions, motivation to do a task, cognitive ability in line with developmental age and how the child is processing stimuli as well as how environmental considerations impact on the child’s ability to do the task. Sensory processing is one tool which can be used within the Occupational Assessment and therefore referrals are accepted for an Occupational Therapy assessment and the trained therapist would decide on the appropriate course of intervention based on the needs of the child on assessment.

Q. Can I talk to someone about completing this referral form?
A.Please complete the Query/Contact Form

Q. Do I need to complete a referral form if the child has received previous input for the Gloucestershire Children’s Occupational Therapy Service?
A. If the referral is around an issue that the Gloucestershire Children’s Occupational Therapy Service provided input for and this ended less than 3 months ago please make contact with us to discuss further via the contact/query form

OR If this is a new functional issue please complete the form for a new referral to the service.

OR If this a query around specialist equipment which the child has been provided with by the Gloucestershire Children’s Occupational Therapy Service please contact the locality office directly (contact details were provided with the equipment).

Supporting Documentation

Upload extra documents here
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Please upload any extra supporting documents in PDF format only