Dingley Specialist Children S Centre

Dingley Specialist Children’s Centre 3/5 Craven Road Reading Berkshire Reading RG1 5LF Tel: 0118 322 5366 Fax: 0118 322 6618 Occupational Therapy Referral Form (For children aged 0-18 without an Education, Health and Care plan)

Please note:  We can only accept referrals from a G.P or Paediatrician  If the child has an EHCP (or what was previously a Statement) you will need to refer to the school based OT’s via the CYPIT Health Hub: 0844 406 0979

CHILD’S DETAILS

Child name: Address:

NHS number:

Date of birth:

Gender: Male/Female

Is this child currently undergoing the EHCP process? Parent/guardian’s name:

Yes/No Contact number:

Is this a looked after child (social services) Is this child at risk or under child protection services? Yes/No Yes/No

Please list any diagnoses or relevant medical history:

Autism:

Cerebral Palsy: Quadriplegia Hemiplegia Diplegia other:………………………….

Global Developmental Delay

Developmental Co-Ordination Disorder

Hypermobility

Ex preterm

Other …………………………………………………………………………………………………………………

REFERRER DETAILS: Name of referrer: Referrer signature:

Profession: Referrer contact Number: Date of referral:

REASON FOR REFERRAL:

1. Has this child been seen by the Dingley OT team before: Yes/No

2. If yes, Have parents/school implemented previous recommendations for 6 months or more: Yes/No

3. Are any of the following activities of daily living below what is expected for the child’s developmental age or cognitive ability? Please circle and give additional details if required:

Dressing: top/bottom half fastenings (buttons/zips) shoe laces

Toileting: getting on/off the toilet or sitting safely removing clothing bottom wiping

Feeding: grasping and using a knife and fork effectively unaware of mess around mouth

Handwriting/fine motor: grasping the pencil maturely poor speed poor legibility pain/discomfort/avoidance

scissor skills

Leisure: ball skills bike riding using a swing other:……………..

Seating: within nursery/school environment for feeding/accessing play etc

** Please note assessment only, no provision of equipment **

Sensory processing: e.g. extreme sensitivity to sensory input or poor awareness of it (touch, sound, taste/smell movement etc). Please provide examples below.

**Please note that, on triage, this referral may be forwarded directly to our sensory processing talk for parental/school support and advice rather than a face to face assessment.

 Please attach any relevant reports e.g. paediatrician, school, educational psychologist reports etc  This form should be faxed or posted to the above fax number/address.  Parents will be contacted via post and informed of the outcome of this referral. Thank you, Dingley Occupational Therapy Team