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Monday 18 March 2019
Derbyshire Healthcare NHS Foundation Trust
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Please refer to referral criteria before making a referral.

Derbyshire Healthcare NHS Foundation Trust: Children and Young People's Therapy Service

Parent/Carer Sensory Group Referral Form

Has the child/young person you are referring been seen by our service within the last 12 months? »
Has this referral been discussed with parents? »

Parental consent for information gathering from any professional detailed on this form is required in order to process this referral.   

Section A. Child's Details
Does the child have a diagnosis of Autism? »
Is the child/young person a Looked After Child? »
Information is delivered to the parents/carers lecture style. Please indicate if the parent/carer can access this.  »
Interpreter required? »
Section B. Referrer Details (We only accept referrals from the following sources)
Referrals are taken for triage from the following list (please tick as appropriate): »
Section C. GP and Consultant Details (If appropriate)
Section D. Other Relevant Information

 Are there other professionals involved with the child/young person?

Section E. Reason for Referral

Referrals received will be triaged and a decision made whether or not the referral meets our service specification criteria.

Acknowledgement regarding referral acceptance will be sent to the referrer, and patient/carer.  If the referral is not accepted, it is the referrer’s responsibility to liaise with parents/carers.