Use this form to refer the child to the Paediatric Continence Service or equivalent local service, if the child's symptoms are ongoing.

Download print-ready version of the Referral Form (PDF file)


Name of person completing form: ________________________________________________

Designation: _________________________________________________________________

Contact details: _______________________________________________________________


Date form completed: __________________________   Signed: _______________________

REASON FOR REFERRAL:
Symptoms on-going after following appropriate flowchart OR other concerns raised - see section A below.
For product provision - see section B below.

Section A

Please enclose:

SUMMARY OF INTERVENTION TRIED/TREATMENT UNDERTAKEN:

                                                          

CURRENT MEDICATION:

Drug ________________________  Dose __________________________ Timing ___________________


Drug ________________________  Dose __________________________ Timing ___________________


Drug ________________________  Dose __________________________ Timing ___________________


Drug ________________________  Dose __________________________ Timing ___________________

Section B

Please enclose:

SUMMARY OF INTERVENTION TRIED/TREATMENT UNDERTAKEN:

                                                          

Child expected to attempt toilet training in the future?    Yes / No

If Yes: Toilet readiness assessment to be repeated in 6/12

           Due: _________________________________

If No:  Annual Review to assess:

  • Bowels - any constipation?
  • Bladder - any UTI?
  • Fluid intake

Assess using Continence Assessment Form - Child who has not yet been toilet trained, or local equivalent

  • Size / type / absorbency of product

           Due: _________________________________

CURRENT MEDICATION:

Drug ________________________  Dose __________________________ Timing ___________________


Drug ________________________  Dose __________________________ Timing ___________________


Drug ________________________  Dose __________________________ Timing ___________________


Drug ________________________  Dose __________________________ Timing ___________________