Referral Form

School Referral Form

For Occupational Therapy
Please complete this form as fully as you can. Please allow 10 minutes to fill this in (depending on how much detail you can provide).

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

If you have any questions regarding this Consent form, please contact us - or your child's teacher.

Phone: 0113 3280208

Email: info@junipertreetherapy.com
- 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
- White
- BuddhistChristianHinduJewishMuslimSikhNo religionOther
- School Name
- School Site (if applicable)
- Class
- 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
- 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 state the strengths of the Child/Young Person.
- Please state the areas that you feel the Child/Young Person needs support, and your goals.
- GP
  Practice Name and Named GP
- Social Worker
- Other People Involved
  Please include contact details where possible
- YesNo
- Please describe
- YesNo
- AllergiesAsthmaEpilepsy or seizure disorderHeart problemsBreathing problemsVisual problemsAuditory problemsNo medical issuesOther
- Please describe condition, medication, treatment, triggers, and date that this last presented a problem (e.g. date of last allergic reaction or seizure)
- Please describe any dietary requirements of the Child/ Young Person
- Occupational TherapyPhysiotherapySpeech and Language TherapyPlay TherapyPsychologyCounsellingOther
- I have Parental Responsibility of the childI am a teacher or other professional
- Assessment and ObservationConsultationTreatmentReview of information held by school (reports, school work, correspondence, etc)
- 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
- 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
- I agree to advise if my child is unwell or diagnosed with any infectious conditions
- 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:

School Referral Form