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Therapies Form

Therapies Form

Please complete all fields marked with an astrix (*)

Personal Information


Sex:

School/Setting Information


Attending*:

SEN Support Plan*:

Educational Health Care Plan (EHCP)*:

Referrer's Information


Referral agreed with parents/carers*:

Other Professionals (If Known)


Referral Services


Has your child had and previous contact with therapy services:

Which service/s are you referring to:

Now please answer the relevant questions sections below

To support them in their daily life does your child use:


Standing Frame

Mobility Aid

Orthotics

Specialist Seating

Other Specialist Equipment

Does this equipment/orthotics need review or adjustment

About the child:


Was your child born before 36 weeks?

For children under 5 years old) Did your child achieve early developmental milestones appropriately?*

If no please give ages achieved for

Does your child have a confirmed or suspected diagnosis?*

Has your child had any investigations/scans/X-Rays?*

Are you concerned about any of the following?


Have you and/or your child attended/participated/used any of the following


Has your child had any investigations/scans/X-Rays?

Does your child have a confirmed or suspected diagnosis?*:

Which of these areas are you concerned about:

Pronunciation/Speech

Sounds Dysfluency (Stammering)

Is there a family history of similar difficulties?:

Selective Mutism or Reluctant Talker

Is the child able to speak freely consistently in some situations but not in others?:

Has the setting completed the SM settings pack? (NB if not your referral may be rejected):

Language skills

Are you worried about:

Attention, Listening and Social Skills

Are you worried about:

Is there a family history of similar difficulties?:

Does your child have a confirmed or suspected diagnosis of ASD/ADHD?:

Drinking and Swallowing difficulties

A GP/Consultant referral will be required. Please ensure a medical referral is attached detailing the medical history and feeding concerns.

Attach evidence here: <---- how do we do / reword this

Was there a sudden onset you your child’s difficulties?:

Does your child have any known food intolerances/ allergies?:

Pertaining to eating drinking and/or swallowing. Does your child have chest infections?:

Does your child find it easier to drink liquids or eat solids?:

Is your child able to move their tongue, lips and eyes easily?:

Does your child find controlling saliva easy or difficult?:

Does your child prefer baths or showers?:

Does your child have a dentist?:

Has your child been given a specified diagnosis?:

Medical/Other

Is there a family history of similar difficulties?:

Is there a family history of similar difficulties?:

Not sure/ Multiply difficulties

Has there been a progressive change?:

Has there been a sudden onset of change date?:

Has there been a sudden onset of change date?:

Was your child developing normally before the change?:

Is your child able to move their tongue, lips and eyes easily?:

Does your child find controlling saliva easy or difficult?:

Has your child been given a specified diagnosis?:

Thank you for your enquiry, we will be in touch shortly.