web view physical e.g. posture, gross and fine movement in head, upper limbs, hands and lower limbs,

Web view Physical e.g. posture, gross and fine movement in head, upper limbs, hands and lower limbs,
Web view Physical e.g. posture, gross and fine movement in head, upper limbs, hands and lower limbs,
Web view Physical e.g. posture, gross and fine movement in head, upper limbs, hands and lower limbs,
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North West Assistive Technology

Client Referral Form

Help desk: 0151 529 2022 Fax:0151 529 5485 E-mail: nwat@aintree.nhs.uk

Address: Aintree House, Aintree University Hospital, Longmoor Lane, Liverpool L9 7AL

Website: 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 Male

Address

Postcode

CCG

D.O.B.

NHS No

Tel. No.

Mobile

DIAGNOSIS:

E-mail

Details of all relevant conditions:

Next of Kin/ main contact for Client

Title

Forename

Surname

Relationship to client

Tel.no.

Mobile

Email

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 place

1

2

3

4

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/No

Is a telecare alarm installed to call for emergency help?

Yes/No

Has 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/No

Is a key safe in use? Key safe number if client wants to share this? _ _ _ _ _

Yes/No

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 Contacts

G.P. Details

Title

Forename(s)

Surname

G.P. Code:

Address

Post code

Tel.no.

Mobile

Email

Fax

Social Services or Housing Association Referrer Details

Discipline

Band

Discipline

Band

Forename

Forename

Surname

Surname

Team

Team

Organisation

Organisation

Tel.no.

Tel.no.

Mobile

Mobile

E-mail

E-mail

Wishes to be present on Visit?

Yes/No

Wishes to be present on visit?

Yes/No

Client Details (Page 3)

Surname

Date of Birth

Postcode

Version 11.04