Important

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

Section A. Child's Details

Required
Date of Birth Required
Required
Required
Required
Is the child/young person a Looked After Child? Required
Required
Interpreter required? Required
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) Required
Required
Required
Required
Required
Required
Date of Referral Required

Section C. School Details

Required
Required
Required

Section D. GP and Consultant Details (If appropriate)

Section E. Previous Interventions

Please identify any strategies and advice already tried

*NB: For SENCO referrals, it is compulsory that the child has completed 2x 8week Physical Literacy interventions and little progress has been seen. Please also supply evidence.

(If you would like to provide us with any additional information, please attach)

Section F. Other Relevant Information

Did the child/young person achieve developmental milestones? Required
Does the child/young person have a diagnosis?

Section G: Reason for Referral

Please describe your main concerns for the child/young person in the relevant areas below:

Physical Skills Required
Required
Independence Skills Required
Required
School Skills Required
Required
Referral to Parental Sensory Group Required
Required
Required
Required

Level of Anxiety

Parents Required
School Required
Child Required

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.

Required