I would like to see an Occupational Therapist
Name……………………………………………………….
Address……………………………………………….……
……………………………………………………...………..
…………………………………………………………………
Date of Birth………….…………………………………
CONTACT NUMBER…………………………………………………
Which activities are you having difficulty with? (tick all that apply to you)
Caring for myself | |
Looking after others | |
Looking after my home | |
Using my local community resources | |
Going to work/college/training | |
Travelling from A to B | |
Maintaining a good routine | |
Socialising/Relationships | |
Doing things I enjoy | |
Sign………………………………………………………….
Date…………………………………………………………