REFERRAL TO CHILDREN’S PHYSIOTHERAPY SERVICE

Hertfordshire Children’s Physiotherapy - Referral Form Sept 2001.docPage 1 of 2

FORMS WITH INSUFFICIENT INFORMATION WILL BE RETURNED TO THE REFERRER

Name of Child: / NHS Number:
Date of Birth: / Gender: Male  Female 
Name of Parents/Guardians:
Address: ......
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...... Postcode: ......
Telephone Nos.: / Home: / Work: / Mobile:
GP Name/ Address: ......
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School Name/ Address: ......
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Other Health Professionals Involved: ......
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Diagnosis / Relevant Medical History: ......
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Is an interpreter required? YES NO / If YES, which language?
Has the child been seen by a Physiotherapist before?If so when and what intervention / advice
was provided?......
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I AM REFERRING THIS CHILD BECAUSE THEY MEET ONE OR MORE OF THE ELIGIBILITY CRITERIA FOR CHILDREN’S PHYSIOTHERAPY
The child has a physical, developmental or medical condition that impacts on their physical development and /orfunctional everyday activities.
The child has a condition which causes pain.
The referral will not be accepted if:
  • The child has flat feet, or an in toeing or out toeing gait, where this is the only concern and there is no underlying neurological involvement.
  • The child is over the age of 8 years with an orthopaedic or musculoskeletal condition unrelated to child development. (These referrals should be made to Adult OutPatient Services).

Name of Child: / NHS Number:
PRESENTS WITH:Functional difficulties with:-Mobility□ Ball skills
Postural control□ Stamina
Balance□ Coordination
EXAMPLES OF DIFFICULTIES OR ANY OTHER ADDITIONAL INFORMATION:
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If the child has fine motor difficulties, please briefly describe these:
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RELEVANT BACKGROUND INFORMATION (for example, safeguarding issues, home visit precautions with non-attendance/compliance, looked after child)
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For this referral to be accepted please confirm the following:
Has the person with parental responsibility for this child given consent for the Physiotherapyreferral to be made? YES NO
If the child has fine / gross motor coordination problems have they used / been signposted to the Hertfordshire Community NHS Trust Physiotherapy website? YES NO

Electronic referrals can be made if you have access to a secure email account to either:
OR
Additional report included/available YES NO / If so, where?
Referrer’s Name (Print): / Signed:
Designation:
Address/Base: ......
......
Telephone Number: / Date:
Please return / fax this referral form to:

Danestrete Child Development Centre

Children’s Occupational Therapy and Physiotherapy Dept

Southgate,

Stevenage,

Hertfordshire,

SG1 1HB

Tel: 01438 737782

Fax: 01438 737799

Hertfordshire Children’s Physiotherapy Service

Version 2 (November 2011)Page 1 of 2