Help & Support Professionals Children's Continence Pathway Referral Form 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: A copy of the completed Continence Assessment Form - Child that has been toilet trained OR Continence Assessment Form - Child who has not yet been toilet trained. Copies of all other assessment documentation used, e.g. Intake/Output Chart, Poo Diary, Night Time Diary. If child is suffering from constipation and/or daytime bladder problems - evidence of physical examination carried out by GP/paediatrician. SUMMARY OF INTERVENTION TRIED/TREATMENT UNDERTAKEN: CURRENT MEDICATION: Drug ________________________ Dose __________________________ Timing ___________________ Drug ________________________ Dose __________________________ Timing ___________________ Drug ________________________ Dose __________________________ Timing ___________________ Drug ________________________ Dose __________________________ Timing ___________________ Section B Please enclose: A copy of the completed Continence Assessment Form - Child that has been toilet trained OR Continence Assessment Form - Child who has not yet been toilet trained. Copies of all other assessment documentation used, e.g. Bladder/Bowel Assessment Chart, Toilet Readiness Assessment Chart, Paediatric Assessment Tool for Issuing of Containment Products - refer to Appendices 3a & 3b of the Guidance for the provision of continence containment products to children and young people, and local product requisition documentation. If child is suffering from constipation and/or daytime bladder problems - evidence of physical examination carried out by GP/paediatrician. 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 ___________________ c