1Details of person requesting referral 2Details of child or young person 3OT support required - Part 1 4OT support required - Part 2 5Supporting documentation 6Summary Progress Step 1 Details of person requesting referral Referrer details If you are a parent, carer or school requesting support for a child with sensory processing difficulties, you do not need to make a referral. The first step of the pathway for SPD support is to book on to the ADDvanced Solutions sensory processing awareness training course (parents) or the SPD in education training course (schools) and trial the strategies. We can only accept referrals for further support once you have attended the training. See our information on SPD and how to book onto a course. If you have not attended the training and submit a referral, it will be rejected. Are you a Professional Parent or carer First name Last name Email Address Postcode Find Address Loading addresses... Select Address -- Please select -- Address line 1 Address line 2 (optional) City Postcode Clear postcode/address Use the Lookup Postcode button to find the address.If you cannot find the address, please enter it manually Contact number Is English your first language? Yes No Is an interpreter required? Yes No Which language? Profession Name of organisation Address of organisation Postcode Find Address Loading addresses... Select Address -- Please select -- Address line 1 Address line 2 (optional) City Postcode Clear postcode/address Use the Lookup Postcode button to find the address.If you cannot find the address, please enter it manually Have you been given consent by the parent or person with parental responsibility? Yes No We are sorry but as you have not sought parental consent, we cannot process your request. Who gave consent? Who has parental responsibility for the child you are referring? Please provide contact details for the child's parent(s)/carer(s) who have parental responsibility for the child Name Contact number Email address (optional) Address (if different from child) (optional) Postcode Find Address Loading addresses... Select Address -- Please select -- Address line 1 Address line 2 City Postcode Clear postcode/address Use the Lookup Postcode button to find the address.If you cannot find the address, please enter it manually Add item Is English the family’s first language? Yes No Is an interpreter required? Yes No Which language? No information is required, please proceed to the next page. Details of child or young person Child’s details First name Last name Other names/aliases (optional) Date of birth Gender Male Female Unknown Other Please specify gender (optional) Ethnicity (optional) -- Please Select -- African Any other Asian background Any other black background Any other ethnic group Any other Mixed background Any other White background Bangladeshi Caribbean Chinese Gypsy/Roma White and Black Caribbean Indian Pakistani Traveller of Irish Heritage White and Black Caribbean White and Black African White and Asian White British White Irish Choose one option that best describes your ethnic group or background. We collect information about ethnicity to ensure that we focus on inclusive practice and engage with children across the whole community. We collect and use information under Articles 6 (consent) and 9 (explicit consent) of the Data Protection Act 2018. NHS number (optional) You will find this in your child’s ‘Red book’ or any prescriptions, NHS referral or appointment letters etc. Inputting your child’s NHS number now can really help us to make on-going referrals in the future. Address Postcode Find Address Loading addresses... Select Address -- Please select -- Address line 1 Address line 2 (optional) City Postcode Clear postcode/address Use the Lookup Postcode button to find the address.If you cannot find the address, please enter it manually Details of property ownership for given address Owned/mortgaged Private rented Housing association Don't know Other Give details Name of child's GP Name of GP surgery Has the child had a diagnosis or are they currently receiving medical investigations? Yes No Give details Which professionals are currently working with the child? Is the child in school or nursery? Yes No Name and address of school or nursery Is the child Not school age yet Home schooled Out of education Is an Early Help Assessment Tool (EHAT) in place? Yes No Don't know Is an Education, Health and Care Plan (EHCP) in place? Yes No Don't know Details of others who live at child's address Including parents/carers, tell us who lives at the child’s address First name Last name Date of birth (optional) Relationship to child Add item No information is required, please proceed to the next page. OT support required - Part 1 Details of support required Please complete each section fully, and tell us as much as you can about what concerns you. Which of the following are reasons for your referral? Sitting up independently Accessing the school environment Producing or participating in school work Bathing Toileting Feeding Dressing Getting up and down stairs Getting in and out of the house Motor co-ordination and using their hands Concerns about risk in the home Other Sitting up independently How does this specific issue impact on the child’s development, health and safety right now? Is there a risk of future harm? What has already been tried to help make things better for this specific issue? How can occupational therapy help with this issue? Accessing the school environment How does this specific issue impact on the child’s development, health and safety right now? Is there a risk of future harm? What has already been tried to help make things better for this specific issue? How can occupational therapy help with this issue? Producing or participating in school work How does this specific issue impact on the child’s development, health and safety right now? Is there a risk of future harm? What has already been tried to help make things better for this specific issue? Include details of any interventions and support in place in school. Attach any documentation you have which outlines the support the child receives in school. (optional) If needed, you can select multiple files to upload when the File Upload window appears. To do this, hold down Ctrl and click on each file you want to upload to highlight it, and then press Open. The maximum combined file size of all uploaded attachments on the form must not exceed 15 megabytes. How can occupational therapy help with this issue? Bathing How does this specific issue impact on the child’s development, health and safety right now? Is there a risk of future harm? What has already been tried to help make things better for this specific issue? How can occupational therapy help with this issue? Toileting How does this specific issue impact on the child’s development, health and safety right now? Is there a risk of future harm? What has already been tried to help make things better for this specific issue? How can occupational therapy help with this issue? No information is required, please proceed to the next page. OT support required - Part 2 Feeding How does this specific issue impact on the child’s development, health and safety right now? Is there a risk of future harm? What has already been tried to help make things better for this specific issue? How can occupational therapy help with this issue? Dressing How does this specific issue impact on the child’s development, health and safety right now? Is there a risk of future harm? What has already been tried to help make things better for this specific issue? How can occupational therapy help with this issue? Getting up and down stairs How does this specific issue impact on the child’s development, health and safety right now? Is there a risk of future harm? What has already been tried to help make things better for this specific issue? How can occupational therapy help with this issue? Getting in and out of the house How does this specific issue impact on the child’s development, health and safety right now? Is there a risk of future harm? What has already been tried to help make things better for this specific issue? How can occupational therapy help with this issue? Motor co-ordination and using their hands How does this specific issue impact on the child’s development, health and safety right now? Is there a risk of future harm? What has already been tried to help make things better for this specific issue? How can occupational therapy help with this issue? Concerns about risk in the home Tell us what risks in the home you are concerned about Risk of injury or harm from everyday household items Risk of escaping unsupervised from doors and windows Safety in the bedroom Significant risks around water safety in the home Any other significant risks or concerns Tell us more about your concerns Other How does this specific issue impact on the child’s development, health and safety right now? Is there a risk of future harm? What has already been tried to help make things better for this specific issue? How can occupational therapy help with this issue? No information is required, please proceed to the next page. Supporting documentation Further information Does the child have any other difficulties that OT need to know about? (optional) Difficulties with attention A communication need Pain related difficulties Behavioural difficulties A delay with their development A suspected or diagnosed learning need Sensory processing difficulties Tell us more about your concerns (optional) If you are the parent/carer, have you attended the ADDvanced Solutions Sensory Processing Awareness course? Yes No I'm not the parent/carer Month and year attended (mm/yy) If you are a school have you attended the Liverpool City Council’s OT Sensory Processing Training course? Yes No I'm not from a school Month and year attended (mm/yy) If you are the parent/carer, have you attended the ADDvanced Solutions Sensory Processing Awareness course? Yes No Your referral will be rejected if you have not attended the awareness course and trialled the strategies for 6-8 weeks, as this is the first step of the pathway for SPD support. We can only accept referrals for further support after you have done this. If you have not yet attended the awareness course, find out how to book the SPD sessions. If you are a school have you attended the Liverpool City Council’s OT Sensory Processing Training course? (optional) Yes No Your referral will be rejected if you have not attended the SPD in education training in the first instance. We can only accept referrals to support implementation of strategies and sensory circuits once you have attended the initial training. Find out how to book SPD in education training. Evidence Please attach any supporting documents such as handwriting samples, school reports, medical letters to help support this referral. If you are a SENCO please attach the child’s SEN support plan or one page profile. Without these documents we may not have sufficient information to accept this referral. Attach documents (optional) If needed, you can select multiple files to upload when the File Upload window appears. To do this, hold down Ctrl and click on each file you want to upload to highlight it, and then press Open. The maximum combined file size of all uploaded attachments on the form must not exceed 15 megabytes. Confirmation Confirmation I confirm that I have read the privacy statement and agree for the information supplied on this form to be shared with the Children's Occupational Therapy Service No information is required, please proceed to the next page. 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 Loading form summary... PreviousNext