Children & Young People’s Therapy Service Referrals

Important

Required
Required
Required
Required

Section A. Child's Details

Required
Required
Required
Required
Required
Required
Required
Required
Required

Section B. Referrer Details (We only accept referrals from the following sources)

Required
Required
Required
Required
Required
Required
Required

Section C. School Details

Required
Required
Required

Section D. GP and Consultant Details (If appropriate)

Section E. Previous Interventions

*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

Required

Section G: Reason for Referral

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

Required
Required
Required
Required
Required
Required
Required
Required
Required
Required

Level of Anxiety

Required
Required
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.

Hide this section
Show accessibility tools