Occupational Therapy request - relative, friend, carer or advocate

About you, the referrer
Have you gained the consent of the person you are referring?


E.g. relative, carer, advocate
Who shall we contact if we need to do a telephone assessment?



About the person you are referring
e.g. Mr, Mrs, Dr
Address
 

Use the Lookup Postcode button to find the address.

If you cannot find the address, please enter it manually

Gender




Occasionally we use technology such as Skype and WhatsApp as part of the assessment process. Does the person you are referring or their family or friends have access to this technology?


Do they receive any of the following benefits?







Do they currently receive any support from a social worker, physiotherapist, community occupational therapist, the incontinence service, or an NHS community occupational therapist?


About their medical or health conditions
Please do not use abbreviations
About their home
Is their property a




Is their property




Do they live



Are they hoping to move?


What do they need help with?
Tell us they you need help with






Stairs
Bathing
Does their bathroom have




Do they use any of the following?








Access to property
How do they currently access the property?



Do they use any aids such as a walking stick or grab rail to enter and exit the property?


Please tell us what aids they use







Toileting
Do they use any equipment or rails to assist them getting on and off your toilet?


Please select which aids they use







Please specify



Kitchen tasks
Can they carry hot drinks and meals safely from their kitchen area?


Bed or chair tasks
Do they need help getting in and out of a chair?


What type of chair seat do they use?







Do they use any equipment to help get out of bed?


Please specify





Additional information

Before you submit this form please review your answers below. If you need to change anything, use the 'previous' button on the bottom left to go back to a section. Then submit the form by selecting the 'Submit button' at the bottom of this page