Yes No Name of person with parental responsibility: Signature of person with parental responsibility: Date: Children’s Occupational Therapy Supporting Information – The following information is required so that decisions around accepting referrals can be made quickly and contains all the necessary information to complete clinical screening. Please complete the form below to provide the service with information needed in relation to the child who you are referring to occupational therapy. Referrals that do not include the required supporting information will be returned to the referrer for completion. We do not currently accept self-referrals or referrals from parents. Guidance on how to complete the rest of this form: Please read the descriptions below and decide the level of function the child demonstrates and if this has been observed by you or reported by someone else. Please tick the relevant box and add any other comments if you wish. At the end of the referral form please mark the two areas of functional difficulty you have identified as causing significant difficulty. Assistance Dependent Observed by Any other comments Required (Full verbal you (O) or prompting or (Some verbal Reported to physical support prompting or you (R) needed) physical support needed ) Self Care skills – Undressing – zips, buttons, Velcro. Dressing - zips, buttons, velcro, shoelaces, correct orientation of clothes on body Using Cutlery (spoon, fork, knife, chopsticks) Washing & drying: face, hands, body Toileting – getting on/off, hygiene (NOT potty or toilet training or knowing when to go).
Yes No Name of person with parental responsibility: Signature of person with parental responsibility: Date: Children’s Occupational Therapy – Supporting Information The following information is required so that decisions around accepting referrals can be made quickly and contains all the necessary information to complete clinical screening. Please complete the form below to provide the service with information needed in relation to the child who you are referring to occupational therapy. Referrals that do not include the required supporting information will be returned to the referrer for completion. We do not currently accept self-referrals or referrals from parents. Guidance on how to complete the rest of this form: Please read the descriptions below and decide the level of function the child demonstrates and if this has been observed by you or reported by someone else. Please tick the relevant box and add any other comments if you wish. At the end of the referral form please mark the two areas of functional difficulty you have identified as causing significant difficulty. Assistance Required (Some verbal prompting or physical support needed ) Dependent (Full verbal prompting or physical support needed) Observed by you (O) or Reported to you (R) Any other comments Self – Care skills Undressing – zips, buttons, Velcro. Dressing - zips, buttons, velcro, shoelaces, correct orientation of clothes on body Using Cutlery (spoon, fork, knife, chopsticks) Washing & drying: face, hands, body Toileting – getting on/off, hygiene (NOT potty or toilet training or knowing when to go).
OT-referral-form-March-2018.docx