Hounslow Children's Therapies Service - Digital Referral Form

We have summarised below some key information. By selecting "Yes, I acknowledge and confirm" at the bottom, you are confirming that you have read, understood and accepted the terms listed in this paragraph and the relevant HCH privacy and digital policies (https://www.nwlondonicb.nhs.uk/), as per points 1 to 6 below: 

1. Hounslow Community Healthcare (HCH)                                                       

This NHS Trust imposes restrictions on the use of any personal information you provide with the aim of protecting personal data and your privacy.

2. UK Data Protection Legislation
Under the General Data Protection Regulations, we have a legal duty to protect any information we collect from you. We keep strict security standards, including encryption software, to prevent any unauthorised access to it. We do not pass on your details to any third party.

3. Website data
We collect anonymised information or data about you when you use our website. This includes: questions, queries or feedback you leave, including your email address if you send an email to us.

4. Website cookies
The HCH website puts small files (known as ‘cookies’) onto your computer or mobile device to collect information about how you browse the site. We use cookies to store information about how you use the West London Trust (WLT) website, such as the pages you visit. They cannot be used to identify you personally. If you wish to restrict or block the cookies which are set by our websites, or indeed any other website, you can do this through your browser settings.

5. Accepted referrals  will be placed on a waiting list and parents/guardian will be notified by a telephone call to arrange the date and time of the appointment and a letter with confirmation will be emailed to the parent/guardian. The referral information provided is protected by UK data protection legislation and separately by the common law duty of confidence. 

6. Authorisations  With this referral, you are authorising staff to view information held on the Electronic Patient Record about the baby/child/young person and share information with another organisation and professionals, e.g. Health Visitor, G.P., Physiotherapy, Paediatrician, etc.

You are authorising staff to share appointments by email to your personal email address and responding to emails in order to maintain on-going communication in relation to the care of the baby/child/young person.

You are authorising the therapist to visit the baby/child/young person in the educational setting as appropriate, including a supervised student therapist to work with the baby/child/young person in order to develop their clinical expertise.

When you submit this form, we will process this information under the data protection legislation. This processing is necessary for health and social care purposes. Under the law, there may be times when we will share information but are not required to seek your consent.

Please be aware your information/data may be shared with the doctor, referrer, parent/carer/guardian and education setting if needed. It is our legal duty to ensure your information is confidential. We protect personal information under common law rules of patient confidentiality and will share information with those members of our partnership who are providing care.

Please be aware that referrals to the services can only be submitted from specific settings. See below for details:

OT - Occupational Therapy - Both Healthcare and Educational Professionals.

PT - Physiotherapy - Only Healthcare Professionals.

SaLT Dysphagia - Both Healthcare and Educational Professionals. 

PT - Physiotherapy

Please be aware that PT requests for patients older than 16 years old and with reference to MSK will be diverted to MSK Adult Services.

In addition, PT Service is not commissioned to accept referrals for hand injury.

Please refer to the following link for further information: https://www.westlondon.nhs.uk/our-services/hounslow-community-healthcare/adult-services/hand-injuries

SLT - Communication

Referrals being completed by education staff for school aged children (Reception and above) may be declined If not supported by the following information:

1. A completed Language Screener (not required if the child/young person has a recent Speech and Language Report).
2. Information on interventions implemented in school to support the child/young person’s speech, language, and communication needs.
3. Reminder: School staff are meant to complete a language screener for children at school age, then complete 2 terms of interventions and eventually complete a secondary screener prior to refer to the specialist service.

SLT - Dysphagia

• Please note referrals for typically developing children with delayed weaning progression (such as issues with chewing development, texture progression, taste progression, etc.) will NOT BE accepted.
• The HCH Dysphagia Service is NOT commissioned to provide a Sensory Behavioural Feeding Service.
• For support with weaning skill development ("introducing solid food"), refer to: 

• https://hrch.nhs.uk/services/search-services/health-visiting-hounslow
• https://www.nhs.uk/conditions/baby/weaning-and-feeding/
• https://www.nhs.uk/start-for-life/baby/weaning/
• https://healthiertogether.hrch.nhs.uk/parentscarers/Feeding-nurturing/Introducing-Solid-Foods

• For sensory based feeding issues please refer to Paediatric Occupational Therapy, within this referral (please tick the option at the very top, just under the T&C).

• If you are concerned about your child’s swallow safety and they are showing any of the signs listed below, please contact your GP to request a review and discuss referral to the Dysphagia service: 
  • Coughing/ choking whilst eating/drinking (happening regularly i.e. several times every day)
  • Changes to colour (face going red or pale) when eating/ drinking
  • Eye watering
  • Wet voice immediately after eating/ drinking
  • Changes to their breathing pattern during and after eating/drinking.

OT - EHCP Section F

Please note, the Hounslow Children’s OT service has specific criteria for accepting children with OT intervention included in Section F and it is currently NOT commissioned for this service. Please refer to the Hounslow Children’s OT Referral Criteria document for more information (found at: https://www.westlondon.nhs.uk/our-services/hounslow-community-healthcare/childrens-services/childrens-occupational-therapy-ot).

Please take note of the following information before continuing with the below OT referral form:

- The completed referral form must include evidence and examples of the child or young person experiencing significant delay/differences/difficulties/needs within functional activities of daily living.

- For referrals being completed by education staff, information needs to be provided on what support strategies have been implemented prior to making the OT referral. Without this information and evidence, it is likely that the referral will be declined.

- In relation to upper limb, please be aware that OT can only accept the referral if the baby/child/young person has a diagnosed neurological condition.

- In regards to equipment referrals, a baby/child/young person under 5 years old can be referred into the service however, for a baby/child/young person 5 years or older the referral will be signposted to the Borough of Hounslow Social Service OT team.