Home Physiotherapy Self Referral Form

Physiotherapy Self Referral Form

Self-referral is available for adults over 16 who need support and advice to manage symptoms related to muscle strains/joint sprains/back and neck pain.

This referral option is not available if you are under the care of a consultant for this problem, or if you have neurological/respiratory/continence conditions. If you have Pregnancy related pain, please ask your GP/Midwife to refer you to the Pelvic Health/ Women’s Health Physiotherapy Service who do not currently accept self-referrals.

Physiotherapy Referral Form

  • DD slash MM slash YYYY
  • DD slash MM slash YYYY
    Please be reminded that Direct access physiotherapy in SEHSCT is only available to prospective clients of 16 years and over.
  • Please enter your email address if you have access to an email account and wish to receive confirmation of your request.
  • A telephone number is essential as this is the preferred method of communication with our service users. To ensure a timely response to your request for treatment, please ensure you have entered a telephone number where you can be contacted. If you do not have a home telephone number, please provide an alternative.
  • Hidden
    If you answered YES to any of the questions above and you HAVE NOT seen a doctor for this symptom, it is essential that you arrange for URGENT advice from your GP or attend your local Emergency Department DO NOT SEND IN THIS FORM UNTIL YOU HAVE SOUGHT FURTHER ADVICE

While you are waiting if you are concerned that your condition is worsening please seek medical advice.

Contents