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 ___________________
