This referral form MUST be completed by a health or social care professional only. Please do not complete if you are the parent/carer.

If you have selected 'yes' to the question below, please continue completing this form.

If you have selected 'no', please speak to a health or social care professional to make a referral for you.

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Referrer's address
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Date/time Field
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Please provide us with at least one mode of contact that we can use to communicate with the parents/carers.

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Professionals involved

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Equipment/seating/posture

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Adaptations/Minor Works

The adaptations will be assessed for need of the child in line with Disabilities Fund Grant (DFG) process from Milton Keynes Council.

Any works needs to be approved by the owner of the property.  

The family and the owner need to agree that the family can remain in that property for at least five years once adaptation works are completed. 

If the home is owned by Milton Keynes Council, a housing association or private landlord, the family may be asked to move house by these organisations.

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Please describe specific functional difficulties. If you have not selected this option, please write ‘not applicable’

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Housing

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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.

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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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