<p> 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)</p><p>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 </p><p>CHILD’S DETAILS</p><p>Child name: Address:</p><p>NHS number:</p><p>Date of birth:</p><p>Gender: Male/Female</p><p>Is this child currently undergoing the EHCP process? Parent/guardian’s name:</p><p>Yes/No Contact number:</p><p>Is this a looked after child (social services) Is this child at risk or under child protection services? Yes/No Yes/No</p><p>Please list any diagnoses or relevant medical history:</p><p>Autism: </p><p>Cerebral Palsy: Quadriplegia Hemiplegia Diplegia other:………………………….</p><p>Global Developmental Delay</p><p>Developmental Co-Ordination Disorder </p><p>Hypermobility</p><p>Ex preterm </p><p>Other …………………………………………………………………………………………………………………</p><p>REFERRER DETAILS: Name of referrer: Referrer signature:</p><p>Profession: Referrer contact Number: Date of referral:</p><p>REASON FOR REFERRAL:</p><p>1. Has this child been seen by the Dingley OT team before: Yes/No</p><p>2. If yes, Have parents/school implemented previous recommendations for 6 months or more: Yes/No</p><p>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: </p><p>Dressing: top/bottom half fastenings (buttons/zips) shoe laces </p><p>Toileting: getting on/off the toilet or sitting safely removing clothing bottom wiping </p><p>Feeding: grasping and using a knife and fork effectively unaware of mess around mouth</p><p>Handwriting/fine motor: grasping the pencil maturely poor speed poor legibility pain/discomfort/avoidance </p><p> scissor skills </p><p>Leisure: ball skills bike riding using a swing other:…………….. </p><p>Seating: within nursery/school environment for feeding/accessing play etc</p><p>** Please note assessment only, no provision of equipment ** </p><p>Sensory processing: e.g. extreme sensitivity to sensory input or poor awareness of it (touch, sound, taste/smell movement etc). Please provide examples below.</p><p>**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. </p><p> 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</p>