Community Therapy Team - self-referral

Is the community therapy team the right service? Read about the team on our web page.

The community therapy team accept patients who:

are registered with a Bournemouth, Poole or Christchurch GP
are 18 years of age or over
are medically stable and safe to be in the community (we are not an urgent, intermediate care or rapid response service)
has community-based goals or can’t be seen in an outpatient setting.

A member of the team will review the self-referral within 72-hours. We may contact you for further information and if the referral is more appropriate for another service we may forward it on your behalf. By completing this form you are in agreement with this.

Please refer to our 'While You Wait' page for helpful resources and information.

Are you completing this form for yourself or on behalf of someone else? Required

If for someone else, please tell us - what is your relationship to the patient, your name and contact details. Please ensure the patient is aware of this referral if you are completing on their behalf.

Who is the primary contact for this referral? Required

Name of patient Required

Patient's address Required

Address 1

Address 2

City

Country

County

Postal Code

Patient's date of birth Required

Patient's NHS number (if known)

Patient's phone number Required

Patient's email address

Patient's GP name and practice Required

Is this referral regarding a new condition or an existing problem?

Please explain the reason and goals for the referral Required

Please include details of any relevant past medical history

What is your normal level of function and mobility? Please include details of abilities or difficulties with transfers (e.g. getting out of bed, standing up from a chair), standing, walking and aids used/required)

What is your current level of function and mobility?

Have you experienced any falls? If yes, how many in the last week/month/year. Do you know the reason for the fall/s? If you have fallen 2 or more times in the past week, please contact your GP.

Have you been seen by us or another therapy team before?

What have you already tried to help you achieve your goal?

What would you like to happen following this referral?

Please advise of any other relevant information i.e. key codes, lone working, parking restrictions, referrals to other services etc

I agree to the privacy policy

The demand for our service is high, which means we have a waiting list. The length of time you have to wait will depend on your specific treatment and clinical needs, but all referrals are prioritised on an individual basis by experienced clinicians. By submitting this referral, you are acknowledging that the therapy team has a waiting list and you will be contacted in due course.

You might also want to read...

Referral information for healthcare professionals

Community Therapy Team - professionals referral form

Useful links and resources