top of page

HOME
ABOUT
WHAT IS OT?
SERVICES
CONTACT
REFERRAL FORM

Please complete the referral form below to help us better understand your child's needs and challenges. The information provided will help our Occupational Therapist in assessing the child's current abilities and determining the most appropriate intervention.

Our goal is to support your child in achieving greater independence and participation in daily activities at home, school and in the community.

Personal Information

Child's First name*

Child's Last name*

Gender*

Male

Female

Other

Birthday*

Day

Month

Year

Multi-line address

Country/Region

Address

City

Zip / Postal code

Parent/Carer Phone Number*

Email*

Background Information

School/Nursery*

Year Group

Address*

My child has an EHCP (Education and Healthcare Plan)

Past Medical History *

Including any clinical diagnosis

Were there any complications during pregnancy or birth?

Yes

If yes, please describe

Has the child met their developmental milestones on time?

Sitting

Walking

Speaking

Reason for referral*

Please describe the main concerns or reasons for this referral

Functional Areas of concern (Please check all that apply):

Fine Motor Skills (Eg. Handwriting, using scissors)

Gross Motor Skills (Eg. Balance, coordination)

Sensory Processing (Eg. sensitive to sounds, textures)

Self-Care Skills (Eg. Dressing, feeding)

Attention and Concentration

Social Skills and Play

Consent

I consent to this referral and for the Occupational Therapist to complete assessments, carry out therapeutic interventions, provide recommendations, resources and training, as deemed necessary for my child. I understand this intervention may be carried out in my absence at school or nursery.

VIKIDS Occupational Therapy use electronic health records via Qunote which is a secure clinical note recording system.

I give permission for relevant data about me/my child are recorded and stored in Qunote.

I give permission for relevant information about my child needs to be shared with other staff/professionals involved in my childs care (eg. School staff, Speech and Language Therapist).

I give consent to be contacted by phone.

I give consent to be contacted by email.

I understand that I can withdraw consent at any time.

Parent/Guardian Signature*

Signature field is empty.

Privacy Policy

bottom of page