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Monday 19 August 2019
Derbyshire Healthcare NHS Foundation Trust
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Children & Young People’s Therapy Service Referral Form

» Indicates required fields

Has the child/young person you are referring been seen by our service within the last 12 months? »
Has this referral been discussed with parents? »

Parental consent for information gathering from any professional detailed on this form is required in order to process this referral.   

Section A. Child's Details
Is the child/young person a Looked After Child? »
Interpreter required? »
Section B. Referrer Details (We only accept referrals from the following sources)
Referrals are taken for triage from the following list (please tick as appropriate): »
Section C. School Details
Section D. GP and Consultant Details (If appropriate)
Section E. Previous Interventions
Please identify any strategies and advice already tried:

*NB: For SENCO referrals, it is compulsory that the child has completed 2x 8week Physical Literacy interventions and little progress has been seen. Please also supply evidence.

(If you would like to provide us with any additional information, please attach)
Section F. Other Relevant Information
Did the child/young person achieve developmental milestones? »
Does the child/young person have a diagnosis?
Section G: Reason for Referral

Please describe your main concerns for the child/young person in the relevant areas below:

Physical Skills »
Independence Skills »
School Skills »
Referral to Parental Sensory Group »

Level of Anxiety:

Parents »
School »
Child »

Referrals received will be triaged and a decision made whether or not the referral meets our service specification criteria.

Acknowledgement regarding referral acceptance will be sent to the referrer, and patient/carer. If the referral is not accepted, it is the referrer’s responsibility to liaise with parents/carers.