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About West-Gate

Book an appointment

Self-referral

Occupational Therapy self-referral form

Take the first steps to confident independent living with restored quality of life by filling in our self-referral form below.

Once we have received your completed form, a member of the team will be in touch to discuss next steps.

Not sure if Occupational Therapy is right for you?

Get in touch, we're happy to help you figure out the best service for your needs.

Occupational therapist assisting a patient with clothing

Section 1: Personal Details

First name*

Last name*

Birthday*

Day

Month

Year

Address

Phone*

Email

Preferred Method of Contact

Phone

Email

Letter

GP Name & Practice

Emergency Contact Name

Emergency Contact Number

Relationship to You

Section 2: Medical History

Current Diagnosis / Diagnoses*

Date of Diagnosis (Estimated)*

Current Medication

Relevant Medical History

Section 3: Lifestyle & Daily Functioning

Do you drive? *

Yes

No

If yes, do you have any concerns about driving related to your condition?

Are you employed?

Yes

No

Job Role / Occupation

Do any of your symptoms affect your ability to work?

Section 4: Areas of Difficulty

A. Physical (e.g., weakness, poor coordination, fatigue)

Describe any physical difficulties you are experiencing:

How do these affect your daily activities (e.g., dressing, cooking, mobility)?

B. Sensory (e.g., vision, hearing, numbness, pins and needles)

Describe any sensory issues:

When did you first notice these symptoms?

Do they affect safety or independence at home or outdoors?

C. Cognitive (e.g., memory, attention, planning, multitasking)

Describe any cognitive challenges:

How do they impact your routine (e.g., remembering appointments, tasks)?

D. Psychological (e.g., mood changes, anxiety, motivation)

Have you experienced any emotional or behavioral changes?

Yes

No

If yes, please describe:

How are these changes affecting your ability to carry out daily tasks?

E. Environmental (e.g., home setup, adaptations, equipment needs)

Do you use any equipment (e.g., walking aids, grab rails)?

Yes

No

Describe any difficulties within your home environment:

Are there any adaptations you think might help (e.g., stair rails, bath aids)?

Section 5: Summary and Goals

What are your main concerns or priorities at the moment?

What do you hope Occupational Therapy can help you with?

Section 6: Consent & Declaration

By signing below, I confirm that the information provided is accurate to the best of my knowledge and I consent to this referral being processed.

Signature*

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Date*

Day

Month

Year

The West-Gate Clinic

Expert care.

Patient centred approach.

Long-lasting outcomes.

28 West-Gate, Driffield, East Yorkshire, YO25 6SY

info@thewestgateclinic.com

Opening hours

Monday - 9:00 AM - 8:00 PM

Tuesday - 9:00 AM - 6:00 PM

Wednesday - 9:00 AM - 6:00 PM

Thursday - 9:00 AM - 6:00 PM

Friday - 9:00 AM - 6:00 PM

Saturday - Closed

Sunday - Closed

© 2026 by The West-Gate Clinic. All rights reserved.

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