EMERGENCY PHYSIOTHERAPY SERVICE
GLOUCESTERSHIRE RESIDENTS ONLY
Please complete the form below for referral for an online physiotherapy consultation about t
he
PERSON THAT YOU CARE FOR
ONLINE PHYSIOTHERAPY CONSULTATION
This service is for Carers living in GLOUCESTERSHIRE, who need one session of advice to
understand the impact/prognosis of a diagnosis/injury/operation for
the person that they care for,
to know what to look out for, and
to safely provide care within their own physicality
The service is provided by KIMBERLY MORRIS BSc (Hons) Physiotherapy
Member of the Chartered Society of Physiotherapy (MCSP)
Specialisms are:
Paediatric and adult musculoskeletal physiotherapy, with particular expertise in infant developmental assessment; orthopaedics; neurodevelopmental management; neuromuscular and neurological conditions; and respiratory management involving suction and manual techniques training
Kim says: “I love working closely with parents, carers and healthcare professionals to provide sensitive and effective care”. To find out more about Kim
click here
Completing the Form
Please complete the form fully, giving as much information as possible.
Once you are at the front of the waiting list the physiotherapist will contact you to arrange an appointment for online advice.
First Name
This is required.
Surname
This is required.
Email address
This is required.
Phone Number
Please tell us a number that we could contact you on
Please tell us a mobile contact number we could contact you on
Postcode
Please tell us so the physiotherapist can see you
Cared for person's additional needs
Please highlight all that apply, hold down the control key and click to select.
Austism Spectrum Disorder
Global Development Delay
Learning Disability
Profound and Multiple Learning Disabilities
Physical Disability
Wheelchair User
Long Term Health Condition
Mental Health Condition
Sensory Impairment
Stoma/Gastrostomy
Tracheostomy/Severe breathing difficulties
Other
Please help us to understand the needs of your family
Cared for person's other additional needs
What would you like advice about?
Please describe what diagnosis/injury/operation you would like advice about
Please share your experience
Do you have any medical conditions or disabilities which may affect your ability to provide care?
Please give a brief description
FEEDBACK
The Parent and Carer Alliance C.I.C. is only able to get funding to provide services such as this one, through Grant funders, such as the Carers Gloucestershire Legacy fund and the Gloucestershire Community Foundation.
For funding to continue to be given, the Alliance needs to demonstrate how the support we provide helps families like yours.
We need YOUR HELP and FEEDBACK
to do this, as telling us what worked for you, helps funders understand why these services are needed
Agreeing to Give Feedback
Yes I agree to give feedback to help with future funding
No
Please select one option
CONSENT TO SHARE
I have read and understood the Parent and Carer Alliance Privacy Policy,
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to read the Privacy Policy
By proceeding, I consent to my personal data being collected and used as stated in the Privacy Policy, and in this Notice:
The Parent and Carer Alliance wish to collect and use this personal information for the following reasons:
To enable you to share information necessary for signing up for, and getting appropriate support from, services such as the Physiotherapy service
, advocacy, training, information events, social activities and outings;
To provide you with support and guidance that is tailored to your needs;
To provide relevant future events/training and services by understanding your personal situation and experiences;
To help us to demonstrate need both locally and nationally to help the Parent and Carer Alliance work effectively with other organisations to improve the services provided;
To access funding sources to develop what we can offer to our members and to offer reduced price support;
To request feedback from you about what you think about any service or support provided to you by the Parent and Carer Alliance e.g. feedback to the Carers Gloucestershire Legacy fund and the Gloucestershire Community Foundation on the impact of advice and support that you have received as a direct result of their providing funding, which may involve them contacting you; and
To track information about the use of our website including information obtained via cookies to develop the website.
You can withdraw your consent to share your information at any time without detriment by email to info@parentandcareralliance.org.uk
CONSENT TO SHARE
YES I DO consent to share this to access support from the Physiotherapy service
No
Please select one option
Submit
Please click the submit button below to send this form. Once the button is clicked a please wait message should appear, then disappear and be replaced by a thank you message at the TOP of the form. You will then be emailed a copy of the form, showing that it has been submitted.
If this doesn't happen, please scroll up for any error messages, as questions with a red star need to be answered for the form to submit. Any issues
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to contact us
Submit
AFTER CLICKING SUBMIT
SCROLL UP
TO CHECK THAT 'THANK YOU' MESSAGE APPEARS. YOUR PLACE WILL BE CONFIRMED ONCE YOUR PAYMENT IS RECEIVED
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