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Lincolnshire Community Health Services Children's Therapy Services

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Rapid response referral form

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Rapid response referral form

Please note, by completing this form, you will be contacted by text, phone and email regarding the child. If you do not wish to be contacted, please inform the service by calling 01522 309025 or emailing LHNT.lincschildrenstherapyservice@nhs.net.

Rapid response – request for help

Name: Required

Gender: Required

None

Female

Male

Date of Birth: Required

NHS no:

Address: Required

Address Line 1

Address Line 2

City

County

Country

Postcode

What is your ethnic group? Choose one option that best describes your ethnic group or background. Required

Please state your religion or belief. Required

Telephone no: Required

Name and contact number of Parent/Guardian or Next of Kin:

Education/adult care provision if appropriate:

Consultant:

GP Name:

Health Visitor:

Other Health Professionals Involved:

Do they receive paid care:

Yes

If so, how many hours:

Who provides that care:

Are any other people involved in persons care:

Is the person subject to DOLS?

Does the person being referred know of this referral?

Yes

Does the main carer/parent know of this referral?

Yes

Have they given their consent to being referred:

Yes

If NO please explain the circumstances:

Diagnosis/Medical History: (Please attach any recent relevant medical/developmental reports)

Hearing and vision: (Including the need for glasses, hearing aid etc):

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Get in contact

Address

Lincolnshire Community Health Services NHS Trust,
Beech House,
Witham Park,
Waterside South,
Lincoln,
LN5 7JH

Other information

Telephone: 01522 309025
Email: LHNT.lincschildrenstherapyservice@nhs.net

Useful links

Lincolnshire Community Health Services NHS Trust
NHS 111
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