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Connect Paediatric Assessment Services Referral

Get in touch today, one of our specialist paediatric experts will be in touch soon.
All submissions are private and confidential.

Parent/Guardians name

Parent/Guardians surname

Contact Number

Contact email

Address

Childs name

Childs surname

NHI Number (if known)

Childs date of birth

Which areas of child health are you concernd about ?

Allergies

ASD/ADHD

Speech & Language

Nutrition

Physiotherapy / Motor skills

Anxiety / Mental health

Child psychology

Fetol Alcohol Spectrum Disorder (FASD)

Neurodiversity

Sensory and mobility

Handwriting and completing fine motor tasks

Coordination and gross motor tasks, appears clumsy

Managing big feelings

Tolerating sensory experiences

Organisation and Planning

Making and keeping friends

Being understood by others

Expressing their thoughts or ideas

Learning and acheiving at school.

Literacy development / Reading and spelling

Other - please specify below

Previous service providers or GP

Please list all medications and supplements

Do you have medical insurance

Yes

No

How did you hear about us?

I confirm that the information given in this form is true

Thanks for submitting! A member of our team will be in touch with you soon.

"A treatment method or an educational method that will work for one child may not work for another child. The one common denominator for all of the young children is that early intervention does work, and it improves the prognosis."
Temple Grandin

©2021 by Connect Paediatric Assessment Services

One child. One referral. One team.

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