Referral Form - Achieve OT

Achieve OT Referral Form

Achieve Occupational Therapy LTD
35 Park Cottages
Duloe
St. Neots
PE19 5HP

Mobile: 07515 019511
Email: enquiries@achieveot.co.uk
Web: www.achieveot.co.uk

Step 1 of 7

14%

Referral for:(Required)

Occupational Therapy Early Years Assessment (0-5 Years of Age) £300 plus travel and mileage (if applicable)

Consultation – No report. £95

Occupational Therapy Assessment £400 plus travel and mileage (if applicable)

Sensory Integration and PRAXIS Assessment £450 plus travel and mileage (if applicable)

Sensory Attachment Assessment £450 plus travel and mileage (if applicable)

Education and Health Care Report – This cannot be used for Tribunal, only for Education and Health Care Plans. This report can be upgraded to a Tribunal Report, but this will need to be within 3 months from the date on the original report £550 plus travel and mileage (if applicable)

Tribunal Standard as per SEND Directive Please note this does not include attendance at tribunal, this is an additional cost – please see below. £650 plus travel and mileage (if applicable)

Urgent Tribunal Standard as per SEND Directive Please note this does not include attendance at tribunal, this is an additional cost – please see below. £850 plus travel and mileage (if applicable)

Tribunal Attendance – 7 day cancellation £600 plus travel and mileage (if applicable)

Therapy Sessions £80 plus travel and mileage (if applicable)

Joint Occupational Therapy and Speech and Language Therapy Assessment £550 plus travel and mileage (if applicable)

Date of Tribunal Evidence and Tribunal Date – If no date is provided we cannot prioritise the assessment

Personal Information

Child / Young Person's Name(Required)

First Last

Gender(Required)

Male

Female

Non-Binary

Prefer not to state

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of birth(Required)

MM slash DD slash YYYY

Parent/Guardian name(Required)

Parental Responsibility(Required)

Email address(Required)

Mobile phone number(Required)

Parent/Guardian name(Required)

Parental Responsibility

Mobile phone number

Email address

School Information

School(Required)

Type of School(Required)

Mainstream

Special School

Education other than School

Other

School address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code United Kingdom

School Contact Name(Required)

School Contact email(Required)

Education and Health Care Plan

Yes

Applying

Do you consent to us contacting school(Required)

Concerns & Developmental History

Diagnosis(Required)

Current Concerns(Required)

Additional Information

Previous Occupational Therapy Intervention (NHS or Private)(Required)

Adopted?(Required)

Yes

C Section or Natural birth?(Required)

C Section

Natural birth

Please provide term of birth

Any issues during pregnancy?(Required)

Any complications during birth?(Required)

Any complications after birth?(Required)

Breast fed?(Required)

Yes

If breast fed, until when?

If breast fed, any difficulties latching on?

Any other relevant information

Developmental Milestones

Please let us know the age the child reached these milestones along with any comments.

Head Control – age and comments(Required)

Rolling – age and comments(Required)

Sitting – age and comments(Required)

Crawling – age and comments including type of crawling i.e., Bottom shuffled(Required)

Walking – age and comments(Required)

Toilet Trained – age and comments(Required)

Speech – age, first words, and comments(Required)

Dressing/undressing – age and comments(Required)

Buttons?(Required)

Yes

Zips?(Required)

Yes

Motor Skills i.e., riding a bike, balancing, kicking a ball, catching a ball(Required)

Medical History

Any significant illnesses(Required)

Allergies(Required)

Seizures(Required)

Medication(Required)

Hearing difficulties(Required)

Visual difficulties(Required)

Wears glasses?(Required)

Yes

Any form of orthotics(Required)

Functional Abilities

Dressing/undressing, yes or no. Age achieved if relevant, and any comments(Required)

Toiletting, including awareness, yes or no. Age achieved if relevant, and any comments(Required)

Eating, including use of cutlery, yes or no. Age achieved if relevant, and any comments(Required)

Bathing/washing, yes or no. Age achieved if relevant, and any comments(Required)

Sleeping. Age achieved if relevant, and any comments(Required)

Sensory Difficulties

Touch – any comments(Required)

Smell – any comments(Required)

Hearing – any comments(Required)

Balance/Body Awareness – any comments(Required)

Oral Sensitivity – any comments(Required)

Next Steps

Thank you — next steps will take place at the beginning of the week. Once your client file has been created, you will be sent a consent form via our online system (Write-upp) to review and sign; please complete and return it promptly so we can proceed with scheduling and any follow-up actions. Please keep an eye on your junk email just in case.