Therapies Form

Please complete all fields marked with an astrix (*)

Personal Information

First Name*:

Date of Birth*:

Sex:

Male Female

Home Address*:

Parent’s/Guardian's Name*:

Home e-mail*:

Language*:

Ethnicity:

School/Setting Information

School/Setting*:

Attending*:

Fulltime Part Time

SEN Support Plan*:

Yes Unknown

Educational Health Care Plan (EHCP)*:

Yes No Requested

Referrer's Information

Referrer’s Name*:

Referrer’s Telephone*:

Referrer’s Email*:

Referrer's Address*:

Referrer's setting (if applicable):

Referral agreed with parents/carers*:

Yes No

What is/are the Parents/Young person’s main concern/s*:

Other Professionals (If Known)

GP Surgery:

Educational Psychologist:

Paediatrician:

Consultant/s:

Social Worker:

Private Therapist/s:

CAMHS:

Specialist Teaching Service (STS):

Other (please specify):

Referral Services

Has your child had and previous contact with therapy services:

Speech and Language Therapy Occupational Therapy Physiotherapy

If so what dates:

Which service/s are you referring to:

Occupational Therapy Physiotherapy Speech and Language Therapy Not Sure

Now please answer the relevant questions sections below

Occupational Therapy Questions

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

Standing Frame

Yes No

Mobility Aid

Yes No

Orthotics

Yes No

Specialist Seating

Yes No

Other Specialist Equipment

Yes No

If yes please give detail

Does this equipment/orthotics need review or adjustment

Yes No

If yes, which pieces of equipment need reviewing

About the child:

Was your child born before 36 weeks?

Yes No Don't Know

How many weeks?

Birth Weight

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

Yes No

If no please give ages achieved for

Rolling

Sitting

Crawling

Standing

Walking

Does your child have a confirmed or suspected diagnosis?*

Yes No

If yes please give detail

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

Yes No Unsure

If yes please give detail

Are you concerned about any of the following?

Playing Ball Games Movement (eg running, jumping, walking, balance) Handwriting/Recording work Using Scissors Following routines Toileting Bathing Dressing Brushing Teeth/Hair Cutlery Skills

If yes, please give details of how this impacts daily life

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

OT Resource Pack Rainbow Road School Led Handwriting Club Parent Talk

Please explain what supporting strategies have been used and whether they have been successful

Please indicate the specific difficulty/ies and the impact this is having on your child in their day to day life

Any other concerns

Physiotherapy Questions

Please explain what supporting strategies have been used and whether they have been successful*:

Please indicate the specific difficulty/ies and the impact this is having on your child in their day to day life.*:

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

Yes No Unsure

If yes please give detail:

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

Yes No

If yes please give detail:

Speech and Language Therapy Questions

Which of these areas are you concerned about:

Fits / Seizures / Epilepsy Visual Difficulties Hearing Difficulties Swallowing Difficulties Frequent Colds/Ear Infections Head Injury, Encephalitis, Meningitis, Stroke/CVA Other

Please give relevant details:

Pronunciation/Speech

What speech sounds does the child have difficulty saying/what words do they find it hard to say clearly what words do they find it hard to say clearly:

Please give examples of some of the speech sounds/words that your child finds tricky, and what they say instead e.g. says “tar” instead of car Speech Link ID if Key Stage 1:

Please explain what supporting strategies have been used and whether they have been successful:

Please indicate the specific difficulty/ies and the impact this is having on your child in their day to day life.:

Any other concerns:

Sounds Dysfluency (Stammering)

Is there a family history of similar difficulties?:

Yes No Unsure

If yes please give details:

When did the dysfluency start?:

Please explain what supporting strategies have been used and whether they have been successful:

Please indicate the specific difficulty/ies and the impact this is having on your child in their day to day life.:

Any other concerns:

Selective Mutism or Reluctant Talker

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

Yes No

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

Yes No

Who to/where/when can your child speak freely?:

Is there anyone they cannot speak to at all?:

How long has this been a concern?:

Please explain what supporting strategies have been used and whether they have been successful:

Please indicate the specific difficulty/ies and the impact this is having on your child in their day to day life.:

Any other concerns:

Language skills

Are you worried about:

Your child not saying enough words Your child’s understanding of Instructions Your child’s understanding Questions Your child having difficulty with sentences How many words does your child puts together in a sentence

If you have ticked any of the above please give details:

Please explain what supporting strategies have been used and whether they have been successful:

Please indicate the specific difficulty/ies and the impact this is having on your child in their day to day life.:

Any other concerns:

Attention, Listening and Social Skills

Are you worried about:

Play skills Making and maintaining friendships Awareness of danger Following routines Interaction with Peers Interaction with adults

If you have ticked any of the above please give details:

Is there a family history of similar difficulties?:

Yes No Unsure

If yes please give details:

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

Yes No

Please explain what supporting strategies have been used and whether they have been successful:

Please indicate the specific difficulty/ies and the impact this is having on your child in their day to day life.:

Any other concerns:

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?:

Yes No

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

Yes No

If yes, how does this show itself.:

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

Yes No

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

Solids Liquids

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

Yes No

Does your child find controlling saliva easy or difficult?:

Easy Difficult

Does your child prefer baths or showers?:

Baths Showers

How does your child react to their hair being brushed/ washed/ cut?:

How does your child react to you cleaning their teeth?:

Does your child have a dentist?:

Yes No

When were they last seen by the dentist?:

Has your child been given a specified diagnosis?:

Yes No

Please explain what supporting strategies have been used and whether they have been successful:

Please indicate the specific difficulty/ies and the impact this is having on your child in their day to day life.:

Any other concerns:

Medical/Other

Is there a family history of similar difficulties?:

Yes No Unsure

How many weeks? :

Is there a family history of similar difficulties?:

Yes No

If yes please give details:

Please explain what supporting strategies have been used and whether they have been successful:

Not sure/ Multiply difficulties

Has there been a progressive change?:

Yes No

Has there been a sudden onset of change date?:

Yes No

Please give the date:

Was your child developing normally before the change?:

Yes No

What medications is your child taking regularly?:

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

Yes No

Does your child find controlling saliva easy or difficult?:

Yes No

Has your child been given a specified diagnosis?:

Yes No

Which Hospitals do they attend?:

Please explain what supporting strategies have been used and whether they have been successful:

Please indicate the specific difficulty/ies and the impact this is having on your child in their day to day life.:

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