Single Point of Access Referral Form

Prior to undertaking the assessment, the child and family should complete a bladder diary for 48 hours and bowel and night wetting diary for one week, using standard documentation.  Include bladder and bowel diary.

  • Fluid intake (what, when and how much the child has drunk).
  • Frequency and consistency of bowel movements (use Bristol Stool Form chart) expected frequency of nor more than x 3 per day / no less than 3 per week.
  • Any soiling, including time, amount and location.
  • Number of voids, including any wetting (normal range 4 – 7 voids per day)
  • Volume of voids (expected bladder capacity = age x 30 + 30)
  • Any bedwetting with estimated size of wet patch, and time if known

Please provide evidence of the above, if not it may delay the referral.

Bowel and Bladder Diary

Required

If you are thinking of referring a child/young person into the service please complete level 1 check list to ensure it is an appropriate referral into our service, please see the check list below. 
Level 1 - Check list

If the patient has tried the self-advice above and the check list indicates a referral to level 2, please use the referral form below.

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