Physiotherapy Self-referral Form

Self-referral criteria

Please read the following criteria prior to completing the online form to ensure self-referral is the best option for you

  • You must be registered with an Eastern Cheshire Practice
  • Patients below the age of 18 must attend their appointment with a chaperone (children with any development conditions should contact their GP for a referral to specialist paediatric therapy services)
  • Patients who require emergency treatment (immediate, serious and life threatening)
    • Please consult NHS 111 or GP urgently if you have recently or suddenly developed difficulties passing urine or controlling bladder/bowels, numbness or tingling around your back passage or genitals, numbness/pins and needles or weakness in both legs
  • It is important that you do not self-refer if you have any of the following signs or symptoms without consulting your GP first
    • Changes in your bladder and bowel habits
    • A hot swollen joint
    • Constant severe pain and you are unable to find relief
    • Weakness, pins and needles, loss of feeling
    • Unexpected weight loss
  • Please note, the service is NOT permitted to see (Please see your GP)
    • Patients who require emergency treatment (immediate, serious and life threatening)
    • Patients in their own homes (i.e. are housebound in the short or long term)
    • Respiratory conditions
    • Neurological conditions
    • Post amputation (requires a specialist referral)
    • Women’s health problems (except pregnancy related pelvic and/or back pain)
    • Patients who have undergone extensive, complicated surgery, as defined by the operating consultant for an orthopaedic or rheumatological condition which requires specialist intervention

Please also note:

  • You are unable to access this service within 6 months if it is for the same condition
  • Depending on your condition and needs, you may be offered an initial assessment with advice and guidance. For those requiring further treatment sessions, the average required is usually between 1 to 3 however this will be discussed with you at your initial appointment where you and your physiotherapist will set jointly agreed goals
  • Dependent upon the information you enter, you may be eligible to be referred in to the ESCAPE-Pain Programme provided by Everybody Sport and Recreation, as an alternative to physiotherapy. The ESCAPE-Pain Programme provides a number of pain management / advice and support classes over a course of six weeks for patients suffering with pain in the hip and/or knee(s) as a result of osteoarthritis.
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