Referral Form

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? :*

YesNo

Speech & Language Therapy Information

Has your child received support from speech & language therapy over the past 12 months? :*

YesNo

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? :*

YesNo

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? :*

YesNo

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? :*

Referral Information Form

Contact Information

Speech & Language Therapy Information

Occupational Therapy Information

Therapy Priorities

Communication

Co-ordination

Further Information