Self Referral - Smart Paediatrics

Waiting List: Bookable appointments available.

On this page you are able to make a direct self-referral to Smart Paediatrics Occupational Therapy.

It takes approximately 15 to 20 minutes to complete this form thoroughly. Please add details to support your referral and ensure all information is correct.

The service has standardised assessments covering young children and adolescents from around the age of 5 to 21 years.

The service is based in Aylesbury, Buckinghamshire and welcomes referrals from all over the country.

You may book in a free 15 minute telephone call before or after you’ve submitted your referral form:

Contact the Service

Please explain your main reason for an Occupational Therapy assessment and report: *

How well do you feel your child will manage participating in an Occupational Therapy assessment? *

Name of person completing form: *

First

Last

What is your relationship to your child? *

Email address (with consent to send reports/documentation to): *

Phone number: *

Child's full name/preferred name: *

Child's date of birth: *

Child's gender/preferred pronouns: *

Child's main address and postcode: *

Contact details of other family members if applicable: *

Child's school and contact details: *

Child's GP and contact details: *

Please provide relevant information with meeting developmental milestones, relevant diagnoses and most recent hearing and vision test. *

Are there any other services which your child is currently involved with? *

Does your child have any reports from other services you would be willing to share? *

Please indicate if there are any allergies which need to be considered during the assessment process: *

Do you consent to photographs being taken for the sole purpose to include in the Occupational Therapy report? *

I understand that it will take up to one month to receive the Occupational Therapy report. If it is required by a certain date, please clearly state this here: *

Do you give consent for Smart Paediatrics Occupational Therapy to liaise with other relevant professionals? *

Where did you hear about Smart Paediatrics Occupational Therapy? *

I have read and agree to the Service Information page on this website. *

After you have clicked submit, you will have the opportunity to book in a free 15 minute phone call. *

I have already booked/completed my free 15 minute phone call with the service.
I will book in a free 15 minute phone call to discuss my self-referral form with the service.
I do not wish to complete a free 15 minute phone call and will wait to hear further steps from the service.