Referral Form

Children’s Physiotherapy Referrals

How to complete a referral:

• All referrals must be completed by a healthcare professional (such as a GP, Consultant, Allied Health Professional or Nurse). Referrals not completed by a healthcare professional will not be accepted and will be returned to the referrer.
• Please ensure the child or young person meets our acceptance criteria before completing a referral. If you are unsure if the child or young person meets the criteria, please contact us to discuss.
• Please read the form carefully and fill in as much relevant information as you can.
• If you have any reports or clinic letters that will provide further information please attach to the referral form.
• We hope our referral form is easy to complete, however if you have any difficulties please contact us for further advice.
• Send the completed referral form to the address located at the end of the form.

MDT referrals for New to City/Country Pathway:

If you are referring a Child or Young Person who is new to City/Country with complex physical health needs please read the attached document for inclusion/exclusion criteria then refer to the MDT New to City/Country Pathway as appropriate by completing the referral form below.

This referral form can be completed by any agency working with the Child or Young person but it cannot be completed by a parent/carer.