Children’s Occupational Therapy referral form

Referrer details
Are you a


Address
 

Use the Lookup Postcode button to find the address.

If you cannot find the address, please enter it manually

Address of organisation
 

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?


We are sorry but as you have not sought parental consent, we cannot process your request.

Please provide contact details for the child's parent(s)/carer(s) who have parental responsibility for the child
Address (if different from child) - optional
 

Use the Lookup Postcode button to find the address.

If you cannot find the address, please enter it manually

Add item

Child’s details
Gender




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.

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
 

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





Has the child had a diagnosis or are they currently receiving medical investigations?


Is the child in school or nursery?


Is the child



Is an Early Help Assessment Tool (EHAT) in place?



Is an Education, Health and Care Plan (EHCP) in place?



Details of others who live at child's address
Including parents/carers, tell us who lives at the child’s address

Add item

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

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.

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
Tell us what risks in the home you are concerned about





Other
Further information
Does the child have any other difficulties that OT need to know about? - optional







If you are the parent/carer, have you attended the ADDvanced Solutions Sensory Processing Awareness course?



If you are a school have you attended the Liverpool City Council’s OT Sensory Processing Training course?



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.

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

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