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.

Are you a health/social care professional? Required
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Referrer's address Required
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What does this referral refer to? Required
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Child's sex: Required
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Their relation to the child Required

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

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Preferred method of contact Required

Professionals involved

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
Are any other professionals involved with the child’s care? (please tick as appropriate) Required
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If the child attends nursery, what day(s) do they attend?
Does the child have a diagnosis? Required
Does the child have an EHCP? Required
Is the family receiving support from Children & Families Practices or Children’s Social Care (social worker)? If yes, please provide details below. Required
Has the child ever had Occupational Therapy in the past? Required
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Equipment/seating/posture

Does the child use any specialist equipment or are there any environmental diffculties e.g. getting in/out of the bath? Required
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Does the child have existing seating? Required
Is the seating outgrown or broken? Required
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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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Mobility: Required

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

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Housing

Are the parents/carers planning to move house in the next six months?
The house is
Child's ethnic group Required
How did parents/carers 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 parents/carers consent to their child being assessed by an Occupational Therapist? Required
Do parents/carers 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 the child’s nursery/pre-school/school in order to support their development. Do parents/carers consent to this? Required
For some appointments we will send parents/carers a text message reminder. Do they consent to receiving text message reminders? Required
Do parents/carers give our service permission to leave short telephone messages on their mobile phone or landline voicemail? Required

You will receive an email response to your referral request. Please check

your spam/junk folder for our emails.

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