Self Referral - Smart Paediatrics

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 assessments which are suitable to cover young children and adolescents from around the age of 5 to 21 years.

All referrals are screened by the service for suitability through a free 15 minute phone call.

After you have submitted this form, you will be re-directed to Calendly where you must book in this appointment to proceed with your referral.

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? *

If your Occupational Therapy report 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 be re-directed to Calendly to book in a free 15 minute phone call. *

I understand that I must book in a free 15 minute phone call for the service to assess the suitability of my referral.