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    Contact Details

    Child's name *

    Gender *

    Date of birth *

    Address 1 *

    Address 2

    Town / City *

    Post Code *

    Parent/Carer contact name *

    Your email *

    Phone *

    NOTE: There will be no fee for this assessment. If an interpreter is required, this will need to be arranged privately.

    Child's Diagnosis

    Diagnosis *

    Height (cm) *

    Weight (kg) *

    Reason for referral *

    Current car seat or travel method *

    Mobility * (please include details of any mobility equipment used and relevant postural support)

    Transfers *

    Trunk control/deformities *:

    Any Special Needs * (eg tilt, swivel base, feeding tubes, oxygen, pressure relief, challenging behaviour etc)

    Any concerns re: parent/carers health

    Vehicle the car seat will be fitted in *

    Number and Ages of any passengers *

    Additional Comments (Has a specific car seat been identified?)





    Address 1

    Address 2

    Town / City

    Post Code