North West Assistive Technology
Client Referral FormHelp desk: 0151 529 2022 Fax:0151 529 5485 E-mail: [email protected] Address: Aintree House, Aintree University Hospital, Longmoor Lane, Liverpool L9 7ALWebsite: http://www.aintreehospital.nhs.uk/nwat/National Service Specification: https://www.england.nhs.uk/wp-content/uploads/2018/08/complex-disability-equiptment-environmental-controls-all-ages.pdf
Please complete all fields. Incomplete forms will not be accepted. Has the client given consent to this referral? Yes/ No Date of Referral Client’s Details: Title Forename(s) Surname Female MaleAddress
Postcode CCG
D.O.B.NHS NoTel. No.Mobile
DIAGNOSIS: E-mailDetails of all relevant conditions:
Next of Kin/ main contact for ClientTitle Forename Surname Relationship to clientTel.no. MobileEmail
Reason for Referral Summary of eligibility e.g. limited bilateral hand function, unable to use standard remote controllers for TV etc………., unable to access computer.
Goals e.g. access existing computer(please state type), control TV/lamp light/bed, page carer, intercom, landline or mobile phone (state if android, ios, windows mobile). NB door release or opener need fitting by social services, private or charitable funding – for NWAT to control they need to be in place1234
Social Circumstances (Family, Friends, care package, additional support, time spent alone, property type, current access to property e.g. key safe, door release or opener, ramp access)
Has client been referred to ACE North for a Communication Aid? Yes/NoIs a telecare alarm installed to call for emergency help? Yes/NoHas the client been referred to Social Service OT or housing association for adaptations (door opener, door release, ramp access etc.)?
Yes/No
Has the client given consent to NWAT liaison with above agencies as necessary Yes/NoIs a key safe in use? Key safe number if client wants to share this? _ _ _ _ _ Yes/No
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Client Details (Page 2)Surname Date of Birth Postcode
Clients Abilities and Difficulties – Please provide full details. Physical e.g. posture, gross and fine movement in head, upper limbs, hands and lower limbs, spasms
Mobility e.g. ability to transfer, walking equipment used, wheelchair- manual/powered - control type
Communication e.g. type, expressive or receptive difficulties, type of communication aid used, who provided it?
Vision e.g. any difficulties, wears glasses
Hearing e.g. any difficulties, hearing aids
Cognitive e.g. attention, understanding of cause and effect, short and long term memory
Psychological, Motivation for Environmental controls e.g. examples of motivation, relevant mental health
Any other relevant information
Relevant ContactsG.P. DetailsTitle Forename(s) Surname G.P. Code:Address
Post code
Tel.no.MobileEmailFax
Social Services or Housing Association Referrer DetailsDiscipline Band Discipline Band
Forename ForenameSurname Surname
Team TeamOrganisatio
nOrganisatio
nTel.no. Tel.no.Mobile MobileE-mail E-mail
Wishes to be present on Visit? Yes/No Wishes to be present on visit? Yes/NoClient Details (Page 3) Surname Date of Birth Postcode
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