Referral Form

Before you make a referral to us, please make sure you have downloaded and read the following four documents:

(1) Terms and Conditions (2) Safeguarding Policy (3) Privacy, Data Processing & Protection Policy (4) Health & Safety Policy

To make your referral, please complete this form as fully as you can. Please allow 20 minutes to fill this in (depending on how much detail you can provide). It might be easier to fill this in on a laptop/ tablet rather than phone.

If you have any questions regarding this Consent form, please contact us:

Phone: 0113 3280208

Email: info@junipertreetherapy.com

Postal Address: PO Box 501, Leeds, LS17 1LL

Clinic Address (Appointments only): Juniper Tree Therapy, HQ Offices, Nursery Lane, Leeds, LS17 7HW
- Name *
  
  First NameLast Name
- Email*
  example@example.com
- Relationship to Child/Young Person*
- Address*
  Including Postcode
- Mobile Number*
  Please enter a valid phone number.Format: 00000000000.
- Your Occupation/Role
- Name of Child*
  
  First NameLast Name
- Gender*
- Address*
  If Different to Above
- Date of Birth*
  
  DayMonthYear
- Child's Weight (if Known)
  Please specify units and date last weighed
- Asian, Asian British, Asian WelshBlack, Black British, Black Welsh, Caribbean or AfricanMixed or MultipleWhiteOther
- Please specify further if you wish
- BuddhistChristianHinduJewishMuslimSikhNo religionOther
- School Name*
- Year Group
- Teachers Name
- Parent(s)Foster CarersGuardianOther
- Name and relationships of others who live with the child*
  Parents, siblings, pets, step-siblings, etc. Please include ages for other children
- Mobile Numbers of Parent(s)/ Carer(s)
- Email Addresses of Parent(s)/ Carer(s)
  example@example.com
- Occupation/ Role of Parents (if different to Section 1)
- Looked After ChildAdoptedFoster CareInterim Care OrderSupervision OrderResidential CareShared CareSpecial Guardianship OrderOther
- Please specify
- If the child is in Foster/Residential care, lives with adults other than their parents, or has been adopted, what do they know about this?
- Please provide details of the Guardian Ad Litem, if one is appointed for the child
- Please discuss here the main reasons for contacting Juniper Tree Therapy.*
- Please state the strengths of the Child/Young Person.*
- Please state the areas that you feel the Child/Young Person needs support.*
  Please include when you first became concerned about the child
- Please outline your key goals for the child. *
  Please number your goals if it is helpful
- Overly PassiveOverly AssertiveSleepingEatingToiletingStiff/Rigid musclesFloppy/ClumsySensory SensitivitySensory SeekingEmotional RegulationGross Motor SkillsFine Motor SkillsBalanceCoordinationSocial SkillsCommunicationAcademicsSelf-CareBehaviourPlay
- Please expand here
- GP
  Practice Name and Named GP
- Nursery/ School/ College
- Key Professional(s) in School
  E.g. Teacher, SENCo
- School contact details
  Email & Phone if possible
- Social Worker
- Social Worker contact details
  Email & Phone if possible
- Further Professional Involved
  Please include contact details where possible
- YesNo
- Please state any diagnoses the Child/Young Person has*
- Please state any diagnoses the Child/Young Person has.
- Please state any diagnoses the Child/Young Person has.
- Please state any diagnoses the Child/Young Person has.
- Any other diagnoses, please describe as above.
- YesNo
- If yes, please describe restrictions.
- If yes, please describe reason for restrictions (e.g. specific diagnoses, recent surgeries, physical difficulties).
- YesNo
- If yes, please specify details, including (1) contact implications e.g. airborne, ingestion, inhalation, etc (2) the reaction e.g. anaphylaxis, rash, breathing difficulties and (3) identified allergens (e.g. specific food, dust, animal hair, etc).
  1. Mode of Contact 2. Allergen Reaction 3. Allergens
- If yes, please specify treatment including medication.
- If yes, please detail date of last allergic reaction.
- YesNo
- If yes, please specify details, including the any triggers or irritants
- If yes, please specify treatment including medication.
- If yes, please detail date of last asthma attack.
- YesNo
- If yes, please specify type of seizures, duration, symptoms and any known triggers.
- If yes, please specify treatment including medication and seizure management plan
- If yes, please detail date of last seizure.
- YesNo
- If yes, please specify treatment including medication.
- If yes, please detail date of last incident.
- YesNo
- If yes, please specify medication name, purpose, dosage, frequency and any other pertinent information (side effects, contraindications and any other relevant information).
- YesNo
- If yes, please specify any corrections (glasses, contact lenses, screens, surgeries; including dates).
- YesNo
- If yes, please specify any corrections (grommets, hearing aids, surgeries; including dates).
- We sometimes use food, snacks and drinks as part of therapy sessions, in addition to making recommendations using food
- YesNo
- Please consider allergies, intolerances, special diets, cultural, religious or personal choices.
- Please state three favoured snacks for the Child/Young Person
- The Key Adults will often participate in sessions with the child. Please specify any relevant medical information or dietary requirements.
- Please specify if the child/ young person has any difficulties with aggressive, violent or challenging behaviours
- Birth Information
  
  Please complete as many sections as you are able to - leave anything blank that you are not sure of.
- Length of Pregnancy
- Birth Weight
- Were there any pregnancy complications or significant factors? (Any significant stress e.g. medication, injury, life events, hospitalisation)
- Were there any birth complications or significant factors? (Length of labour, delivery method, baby's health, etc.)
- YesNo
- Please describe the child's sleep pattern currently.
- Please describe the child's sleeping pattern as a baby and beyond.
- Please describe the child's activity levels.
- YesNo
- Over-eatingUnder-eatingPicky eatingEating inedible objects/ itemsLack of varied diet
- Please describe method of feeding from birth.
- Please describe the weaning process. (Age, kinds of foods, anything remarkable.)
- Please describe current daily diet. (Food preferences, support needed, over-eating, under-eating.)
- Please describe if your child ever had any difficulties with swallowing or choking?
- Please describe the child's ability to use cutlery (if appropriate)
- YesNo
- Please describe the child's early communication and interaction skills.
  Please include ages for first words and sentences if relevant
- Please describe the child's current communication and interaction skills.
- YesNo
- Playing with peersPlaying alonePlaying with adultsAccessing hobbiesPhysical playRestricted playImaginary play
- Please give any details if any boxes above are ticked.
- Please describe the child's play skills currently, and what they enjoy playing with.
- Please describe the child's play skills as a baby and beyond.
- How much time per day does the child spend playing alone?
- How much time per day does the child spend playing with parents?
- How much time per day does the child spend playing with friends?
- How much time per day does the child spend playing with electronics?
- How much time per day does the child spend watching TV/movies?
- YesNo
- Please identify the child's abilities in the following areas:
- EasyOKChalleningUnable
- Comments
- EasyOKChalleningUnable
- Comments
- EasyOKChalleningUnable
- Comments
- EasyOKChalleningUnable
- Comments
  Please identify age that child was toilet trained, or toileting method they currently/ previously used
- YesNo
- At what age could the child sit independently? Please provide any relevant details.
- At what age could the child crawl? Please provide any relevant details.
- At what age could the child pull to stand? Please provide any relevant details.
- At what age could the child walk? Please provide any relevant details.
- EasyOKChalleningUnable
- Comments
- EasyOKChalleningUnable
- Comments
- EasyOKChalleningUnable
- Comments
- EasyOKChalleningUnable
- Comments
- EasyOKChalleningUnable
- Comments
- EasyOKChalleningUnable
- Comments
- What hand does the child use for:
- Educational and Care Information
- Please outline any settings the child has attended (including ages), such as; child-minder, family carers, nursery, pre-school, respite placements, schools
- YesNo
- Please specify (e.g. a Education, Health and Social Care Plan (EHCP), teaching assistant, or other Educational Special Needs Scheme
- Occupational TherapyPhysiotherapySpeech and Language TherapyPlay TherapyPsychologyCounsellingOther
- Please provide details of this therapeutic input below; please provide details of as many professionals as is required.
- Please enter the information related to the above answer
- Please enter the information related to the above answer
- Please enter the information related to the above answer
- Please enter the information related to the above answer
- Please enter the information related to the above answer
- Please enter the information related to the above answer
- Please enter the information related to the above answer
- I have Parental Responsibility of the childI do not have Parental Responsibility (for example if you are a Professional working with the child, or if you are a Parent of a child currently in the care of the Local Authority)
- AssessmentConsultationTreatment
- Please indicate below with a tick regarding how we may use information about you and your Child.
- GPOccupational TherapistPhysiotherapistSpeech and Language TherapistSocial WorkerPaediatricianPsychiatristSchoolEd PsychologistClinical PsychologistGPOther
- If other, please specify.
- Is there anybody you DO NOT consent for us to contact or share information with*
- If yes, please provide the name of the person, their relationship to the child, and a brief context as to the reasons for withholding consent, if appropriate
- Any of the below specified settings as appropriateHomeSchoolIn the communityIn clinicOther
- If other, please specify.
- Please give details of anywhere you DO NOT consent for us to see you and/ or your Child.
- All of the below specified methods as appropriatePhone (Calls and Texts)Email (Regarding Therapy)Email (Mailing List)FacetimeZoomGoogle Meet/ HangoutWhatsapp (Calls & Video)Microsoft Teams
- We continue to follow guidance from the UK Health Security Agency and NHS England. Please see the following requirements
  - if your child has tested positive for Covid-19 within the past 3 days, they must not attend for therapy
  - if you have tested positive for Covid-19 within the past 5 days, you and your child must not attend for therapy
  - if you or your child any of the following, you must not attend for therapy: a fever, a new and continuous cough, anosmia (loss of smell) or ageusia (loss of taste), unusual shortness of breath, fatigue, loss of appetite, myalgia (muscle ache), sore throat, headache, nasal congestion (stuffy nose)
  As part of our Covid-19 Risk Assessment and Policy, we ask for your consent for face-to-face contact with your child to provide our therapy services.
- I consentI do not consent - please provide more details if you wish
- You and/or your child may participate in sessions where we will video or take photographs. This 'media' (video and photos) is stored securely, and only those with permission from you can view this. Once the media has been used to help our assessment or treatment, it will be destroyed unless further consent is provided below.
  
  We are a learning and teaching service, providing training for parents, teachers, nurses, et cetera. We ask for permission for photos and videos (media) to be used to demonstrate key learning points, to help people better understand the needs of children and young people.
  
  We do this through Juniper Tree Therapy courses, or Sensory Attachment Intervention courses. We will always check the photograph/ video clips with you prior to using them. If you require further information, please do not hesitate to contact us.
- YesNo
- YesNo
- YesNo
- YesNo
- YesNo
- YesNo
- YesNoOther (Please detail any information you do NOT wish to be shared)
- YesNo
- Terms and ConditionsSafeguarding PolicyPrivacy, Data Processing & Protection PolicyHealth & Safety Policy
- Please upload any relevant previous assessments/ reports/ documentation which should be considered along with the information in this form
  
  Cancelof
- Your Name*
  
  First NameLast Name
- Date*
  
  DayMonthYear
  Date
- Signature*
  
  Clear
- Second Referrers Name (if appropriate)
  
  First NameLast Name
- Date
  
  DayMonthYear
  Date
- Signature
  
  Clear
- Should be Empty:

We sometimes use food, snacks and drinks as part of therapy sessions, in addition to making recommendations using food

Birth Information

Educational and Care Information