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    BH Healthhub Cypitreferralform Nov2014

    Uploaded by

    peachypeachy
    The document is a referral form for speech, language, occupational, physical and dietetic therapy services for children and young people. It collects information about the patient, their needs, previous treatments, diagnoses, medications, development history and the reason for referral.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    BH Healthhub Cypitreferralform Nov2014

    Uploaded by

    peachypeachy
    5 views4 pages
    The document is a referral form for speech, language, occupational, physical and dietetic therapy services for children and young people. It collects information about the patient, their needs, previous treatments, diagnoses, medications, development history and the reason for referral.

    Original Title

    Bh Healthhub Cypitreferralform Nov2014

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    © © All Rights Reserved

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    PDF, TXT or read online from Scribd

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    The document is a referral form for speech, language, occupational, physical and dietetic therapy services for children and young people. It collects information about the patient, their needs, previous treatments, diagnoses, medications, development history and the reason for referral.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    5 views4 pages

    BH Healthhub Cypitreferralform Nov2014

    Uploaded by

    peachypeachy
    The document is a referral form for speech, language, occupational, physical and dietetic therapy services for children and young people. It collects information about the patient, their needs, previous treatments, diagnoses, medications, development history and the reason for referral.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 4

    REFERRAL FORM

    Speech and Language Therapy, Occupational Therapy, Physiotherapy and Dietetics Services for Children and
    Young People

    Patient’s name: NHS No:

    D.O.B: Referrer’s Name / Address / Telephone number:

    Male/Female: Referrer’s relationship to child / young person:

    Previous/Other names, (if applicable): Has Parent / Guardian consented to this referral?

    YES / NO
    Address:
    Referrals can only be accepted if parental consent has
    been given. However, you can ring the BHFT SPE Hub for
    advice on how to help if there is no parental consent on
    0844 406 0979

    Email Address/ Are you happy for us to contact you


    and/or send you information regarding your child i.e.
    appointments or reports etc. by email? YES/NO

    Does the patient live alone (if a young person?) Patient ethnicity:

    Nursery/School name and location:

    Child/young person’s main language:

    How are you hoping we can help?

    Please explain the impact of this problem on the child/young person’s daily life

    What have you previously tried and what impact did this have?

    Does the child/young person have a Statement of Special Educational Needs or an Education Health & Care Plan:
    Yes / No / In Progress

    Is an interpreter required for parental discussion: Yes/No/Don’t know


    If Yes what language, (including signing):
    1
    Is an interpreter required for child’s assessment: YES/NO/Don’t know
    If yes what Language , (including signing):

    Are you able to read information if I send it to you? YES/NO/Don’t Know


    Does the child have any allergies: YES/NO
    If yes please specify:

    Has the child had a hearing test: YES/NO


    What date: Where:
    Results
    Has the child had a vision test: YES/NO
    What date: Where:
    Results:

    Has the child/young person received a diagnosis(es): YES/NO

    If YES please specify.

    Current Medications:

    For Dietetics Referrals ONLY accepted from a Paediatrician or BHFT community dietetics services:
    Patient’s weight:
    Patient’s Height:
    Change in weight in centiles over the last 6 months
    Is the referral “Urgent” because of recent or planned surgery? YES/NO
    Please give details and dates:

    Referral concerns are about difficulties with swallowing, eating and drinking: YES/NO
    Is the referral for a Dietician from a Paediatrician, (Acute or Community) about children/young person who is tube
    fed and/or losing weight? YES/NO

    If YES to any of the above send to CYPIT that day, marked urgent.

    DEVELOPMENTAL INFORMATION Can the child/when did the child first:


    Roll over:

    Sit independently:

    Crawl:

    Walk:

    Stand independently:

    Babble:

    Use his/her first words:

    Put words together:

    2
    PLEASE FILL IN SECTIONS BELOW THAT ARE RELEVANT ONLY TO YOUR CURRENT CONCERNS
    AND REASON FOR REFERRAL:

    Information about Speech, Language and Communication needs:


    Finds Can do with Can do well Comments
    Difficult support
    Attention, Listening
    & concentration
    Can understand
    spoken instructions
    and information
    Can use words and
    sentences to
    express
    himself/herself.
    Uses speech Only Some less Everyone
    sounds clearly,( is familiar people can can
    it easy to adults can understand understand
    understand the understand child’s child’s
    child’s speech child’s speech speech
    production? speech
    Does the child use a dummy? YES / NO

    Information about Behaviours:


    Finds Can do with Can do well Comments
    Difficult support
    Plays and engages
    well with other
    children
    Sitting still during a
    task
    Can tolerate
    change in their
    routine
    Will try new foods

    Information about independence skills:


    Finds Can do with Can do well Comments
    Difficult support
    Dressing and
    undressing,
    (including
    fastenings)
    Getting to sleep
    Using cutlery
    Washing and
    drying face, hands
    and body
    Going to the toilet

    3
    Information about Physical skills:
    Finds Can do with Can do well Comments
    Difficult support
    Walking & running
    Balance including
    jumping and
    hopping
    Riding a bike
    Swimming
    Ball skills –
    throwing and
    catching

    Information about Foundation and Classroom Skills:


    Finds Can do with Can do well Comments
    Difficult support
    Drawing & writing
    Using scissors
    Following
    Instructions
    Organisation
    Willingness to take
    part in activities
    directed by others

    He/she avoids certain activities (more than other children of their age):
    Please give an example:

    He/she seeks certain activities (more than other children of their age):
    Please give an example:

    He/she has participated in additional targeted activities and support at school to promote specific
    areas of learning and development.
    Please give details:

    Any other comments related to the child’s/young person’s needs:

    We might contact you in the future to discuss the YES/NO


    service you have received from CYPIT. Are you
    happy for us to do this?
    Return Address:
    Berkshire Healthcare Foundation Trust
    Single Point of Entry Hub
    The Old Forge, 45-47 Peach Street
    Wokingham, Berkshire
    RG40 1XJ

    Email: [email protected]
    Phone: 0300 365 1234 4

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