 Advice on completing the Self Referral form
The Race Record Keeping Form - information and advice
Download the Self Referral form and Race Record Keeping form
Download a sample form to assist you in completing your own form
Advice on completing the Self-Referral Form
The self-referral form gives us a way of gaining information about you, so decisions can be made about whether you need a Specialist Occupational Therapy assessment.
The following information is to help you or your carer complete the self-referral form. We have divided the form up and explained on the opposite page, what to put in each of the boxes on the form.
It is essential that you complete all areas that apply to you and that you write clearly and in BLOCK CAPITALS when possible.
Try to answer the questions as though you are having a "bad day". For example, if you have arthritis and you have joint pain and stiffness in the morning, answer all the questions as though you are performing the task when you do experience joint stiffness. This allows us to understand what you can and can't do when your condition is bad.
If you are unable to complete the form, perhaps you can ask a family member or a friend to help you.
At the end of this pack there is a self referral form we have completed to give you an example of what a completed form looks like.
If you are unable to get assistance or you are experiencing difficulties, you can contact the Occupational Therapy Duty Team on (020) 8871 6270, Monday to Friday between the hours of 9.30am and 12.30pm.
Once completed, please return the Self-Referral Form and the Race Record Keeping leaflet to the address shown on the forms.
Race Record Keeping: A brief explanation
Wandsworth Council is committed to Equal Opportunities.
Wandsworth Social Services Department is looking at the services it provides for the people who live in the borough. To help us with this, we need to know who is using our services, and how.
In particular we need to know people's cultural and racial origins and what languages they use. This will help us to see how services are used by people from different backgrounds, and what changes are needed so that our services are equally useful to everyone in the borough. We need to get rid of any possible discrimination in the services we provide.
We are not asking about nationality. We know already that most people who use Social Services are of British nationality, whatever their origin or colour. People whose families originally came from another country but who have been in this country for some generations may no longer feel most closely identified with their families' original group. However, many people also have social, religious, cultural or historical links with the racial group or geographical area from which they or their parents or families originally come. We know that none of the categories describes anyone perfectly: please use the category that you feel describes you best.
The information you give to us is confidential. It will be used only for the planning of services and will not identify individuals. Individual details will only be shared with other agencies where necessary for the delivery of a specific service.
We very much appreciate your help. If you have any comments or queries about our equal opportunities policy please telephone (020) 8871 7306.
Download forms
 Download the Self Referral form (95 kb)
Download the Race Record Keeping form (37 kb)
Download the sample completed forms (121 kb) - containing essential information about the OT service. Also included are versions of the self referral form and the race record keeping form that have been completed as an example of how you should complete your form.
These documents are available in Adobe's Portable Document Format (PDF). If you do not already have it you can download it for free from Adobe by clicking on the yellow Adobe Reader button below.
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