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> Apply online for an Occupational Therapy Service

Apply online for an Occupational Therapy Service

Fair Processing Notice To find out how we will process and use personal information in connection with this request please see our Privacy Statements.
Label
1. If you are having difficulty with an activity in your daily life like, bathing / showering, getting up / down stairs or getting dressed you may require some advice or practical help to assist you. An Occupational Therapist can help you to identify your needs and find solutions to make life easier for you or someone who cares for you.
Personal details
1. To assist with the initial screening and prioritisation of referrals to the Occupational Therapy service it is important that as much information as possible is provided.
2. Title*
3. First Name*
4. Second Name*
5. Date of Birth*
6. Phone Number
7. Address*
8. City*
9. Postcode*
10. Email
11. Do you live alone?
12. If you do not live alone, then please tell us who else lives with you
Details of person completing the form (if different from above)
1. Details of person completing the form (if different from above)
2. First Name
3. Second Name
4. Address
5. Phone Number
6. Email
7. Relationship
8. Under the new Data Protection regulations, you need to tell someone if you are passing their information onto us. Is the person aware that you are applying for a OT service on their behalf?
9. Label
  
  Yes
  
  No
Additional Details
1. Who owns your home?
2. Housing Association (Name and address)
3. Privately Rented (Name and address)
4. What type of Accommodation do you stay in?
5. If you receive help from any of the services below please select them
6. Label
  
  Homecare
  
  District Nurse
  
  Day Care Centre
Communication
1. Is English your first language?
2. Do you require an Interpreter?
3. If Yes, please provide details?

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