Home – Our services – Physiotherapy – Community outpatient physiotherapy – Middlesbrough, Redcar and Cleveland – Community outpatient physiotherapy self-referral form

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 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 do not accept self referrals for:

  • Under 18s – ask your GP to refer you if you are aged 16 to 18 years
  • Neurological disorders – ask your GP for a referral to neurology at The James Cook University Hospital
  • Stroke rehab – ask your GP for a referral to community therapies
  • Respiratory conditions – ask your GP for a referral to the appropriate service
  • Low back pain/thoracic pain/neck pain if you have previously been assessed by a healthcare professional – ask your GP for a referral to single point of access via triage and treat
  • Patients who are unable to attend an outpatient department and require a home visit – ask your GP for a referral to community therapies

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

  • Whiplash associated disorder

Miscellaneous

  • Assessment for walking aid

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.

If you are completing this form on someone else’s behalf please use their details to complete.

Community outpatient physiotherapy self-referral form

Please tick the box below to confirm that you are not referring under 18s, neurological disorders, stroke rehab, respiratory conditions, low back pain which has been assessed by a healthcare professional within the past two weeks or require a home visit(Required)
Preferred location(Required)
Name(Required)
Address(Required)
DD slash MM slash YYYY
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 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)?

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.

Privacy policy(Required)