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Coronavirus Advice
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Referral Form
Therapy Explained
About Us
Jerome Lejeune
Our Lead Therapists
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Links
Home
Coronavirus Advice
Therapy Sessions
Clinic Costs
Referral Form
Therapy Explained
About Us
Jerome Lejeune
Our Lead Therapists
Contact
Links
Referral Information Form
Please fill in the details in the referral form below.
Contact Information
Child's Name:
*
Child's Age (Years & Months):
*
Child's Date of Birth:
*
Parent's Name/s:
*
Address Line 1:
*
Address Line 2:
*
City:
*
County:
*
Postcode:
*
Contact Phone Number:
*
Contact Email Address:
*
Do you give consent to this form being shared with the relevant practitioners working for the Lejeune Clinic, for the purposes of your child's treatment? :
*
Yes
No
Speech & Language Therapy Information
Has your child received support from speech & language therapy over the past 12 months? :
*
Yes
No
If
Yes
, what kind of support did they receive? :
Occupational Therapy Information
Has your child received support from occupational therapy over the past 12 months? :
*
Yes
No
If
Yes
, what kind of support did they receive? :
Therapy Priorities
What are your priorities for your child’s therapy? :
*
Communication
How does your child communicate, e.g. pointing, gestures, Makaton, words, phrases, short sentences? :
*
Co-ordination
How does your child currently move themselves around their environment? :
*
Do they have difficulty rolling, kneeling, crawling or standing? :
*
Does your child use their hands well when using toys? :
*
Yes
No
Do you have any concerns regarding this? :
Further Information
Please write down any other information you would like to include here:
Where did you hear about the Lejeune Clinic for Children with Down Syndrome? :
*