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Community outpatient physiotherapy self-referral form

South Tees Hospitals NHS Foundation Trust community outpatient physiotherapy self-referral form

Please read before submitting this form

The physiotherapy service can only accept self referrals for people registered with a GP practice in the Middlesbrough, Redcar and Cleveland area. If you live outside this area please contact your GP for advice.

The information you provide on this referral form will be used by a senior physiotherapist to triage resulting in a decision as to whether you need to be seen urgently, soon, or routinely. Please try to avoid ticking multiple body parts, focus on your main issue. There is a free text box to include additional information  with regards to your problem for us to prioritise your referral appropriately. Please note, you can also access the First Contact Physiotherapy Practitioner within your GP practice by contacting your surgery and requesting an appointment. If your self referral is not appropriate for the community outpatient physiotherapy service, your completed referral form will be returned to you.

Community outpatient physiotherapy accept self referrals for:

Peripheral joints

    • Acute joint trauma

    • Joint pain

    • Sprains and strains

    • Soft tissue problems

    • OA joints with acute flare

    • Early onset OA or OA joints waiting for replacement, for advice on damage limitations and exercise

    • Work-related repetitive strain problems

Spinal

    • Neck pain

    • Posture related cervical/thoracic pain

    • Whiplash associated disorder

    • Thoracic pain

Miscellaneous

    • Mobility problems

    • Assessment for walking aid

Community outpatient physiotherapy do not accept self referrals for:

    • Under 18s

    • Neurological disorders

    • Stroke rehab

    • Respiratory conditions

    • Low back pain

    • Patients requiring a home visit should contact their GP practice to be referred to community therapies

If you feel you meet the above criteria please complete the self referral form below.

Please note we will only contact you on receipt of your referral if it is deemed urgent or soon. If your referral is routine, you will be added to our waiting list and we will then contact you when there is appointment availability.

Community outpatient physiotherapy self-referral form

Preferred location(Required)
Address(Required)
Are you pregnant?(Required)
Do you consent to us sending SMS text messages re your appointment?(Required)
Do you consent to the physiotherapy service sharing information with your GP?(Required)
Are you a carer?
Please tick which part of the body you are referring for:(Required)
Please specify which side of the body if appropriate:
For hip pain only – is the hip pain in the front, side or back pocket position?
If yes please give details.
If it was an injury did you attend A&E or an Urgent Treatment Centre (UTC)?
Have you seen your GP or practice nurse within the past 2 weeks for this problem?(Required)

Please bring list of your medications to first appointment.

If your symptoms worsen before you receive contact from us please see your GP or nurse.