Refer a Child for Assessment

Please complete this form if you wish to refer your child for assessment. Once submitted, our team will be in contact with you shortly.

Name of Child *

First

Last

Date of Birth (Day/Month/Year) *

Child's Age *

Name of Parent/Guardian *

First

Last

Home Address *

Postcode *

Home Phone Number

Mobile Phone Number *

Email *

School Your Child Attends *

Please Tick if Applicable To Your Child

• My child has a "Statement of Educational Needs" and/or a classroom assistant.

Medical Information

Allergies

Reason for Referral

Involvement with other health professionals

Which of the following statements best describes your child?

• They can engage in small group activities with some adult support.
• They have difficulty engaging in small group activities even with adult support.
• they have not yet successfully engaged in small group activities with adult support, and usually require 1:1.

Please tick if you consent to the following:

• Taking photo/video footage of participants for use in publicity materials, in line with our social media policy. (Facebook, Instagram, Website)
• Administering basic first aid.
• Applying plasters
• I undertand that physical activity carries a degree of risk, and that staff take all appropriate steps to assess, control, and manage risk.

Link to the social media policy is included below this form.

Please tick below which of the following services you are interested in

• Initial Paediatric Occupational Therapy Assessment -School age Child
• Developmental Occupational Therapy Assessment – infant/preschool child
• Motor skill Assessment Package – 5 years +
• Therapy Session/ Review/Follow up appointment.

Confirm the following: *

• I have read and understand the "Little Lions Group Information Sheet" (See Link Below)
• I have read and understand the Little Lions Therapy Privacy Policy. (See Link Below)

Links to the Information Sheet and Privacy Policy are included below this form.

Please enter your full name in the space below to electronically sign this form: *

Submit

Links to policies and Group Information:

• Privacy Policy
• Social Media Policy
• Group Information

(all links open in a new tab)