Have you completed the advice from the website? Required

If you have selected 'no' you must complete the advice on the website before completing this form. Click here to read the advice.

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Your relation to the child Required

Please provide us with at least one mode of contact that we can use to communicate with the parent/carer.

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Preferred method of contact Required
Who has parental responsibility? Required
Is the child a 'looked-after' child? Required
Does this child have a 'child protection plan'? Required
Does this child have a 'child in need plan' Required

Professionals involved

Are you receiving support from Children & Families Practices or Children’s Social Care (social worker)? If yes, please provide details below. Required
Are any other professionals involved with your child’s care? (please tick as appropriate) Required
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What day(s) does your child attend nursery?
Does your child have a diagnosis? Required
Does your child have an EHCP? Required

Case history questions

Has your child ever had Occupational Therapy in the past? Required
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Are you requesting self-care/toileting input from Occupational Therapy? Required
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Are you requesting washing input from Occupational Therapy? Required
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Are you requesting dressing input from Occupational Therapy Required
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Are you requesting using cutlery input from Occupational Therapy? Required
Are you requesting school skills input from Occupational Therapy. This could include: handwriting, ruler use, scissors, organisation Required
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Are you requesting input from Occupational Therapy for something else that hasn't been listed? Required
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Child's ethnic group Required
How did you hear about us? Required
Do parents/carers have any information or communication needs that we should consider when providing you with information? E.g. Large print, easy read, braille, etc. Required

Consent

By accessing Occupational Therapy Services, parents/carers accept that information regarding their child will be shared with all other health and care providers involved in your child’s care. This is the policy of the Occupational Therapy Service and is nationally best practice in the interest of the child. Electronic patient records are kept on shared systems with other healthcare providers.

Do you consent to your child being assessed by an Occupational Therapist? Required
Do you consent to CNWL Occupational Therapy Service to share in and share out your child’s clinical record with other relevant health and care organisations? Required
It is best practice to share information (e.g. reports and therapy targets) with your child’s nursery/pre-school/school in order to support your child’s development. Do you consent to this? Required
For some appointments we will send you a text message reminder. Do you consent to receiving text message reminders? Required
Do you give permission to leave short telephone messages on your mobile phone or landline voicemail? Required
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You will receive an email response to your referral request. Please check your spam/junk folder for our emails

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