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
    • Respiratory conditions
    • Neurological conditions
    • Post amputation (requires specialist referral)
    • Women’s health problems (except pregnancy related pelvic and/or back pain)
    • Patients in their own homes that do not meet the criteria for domiciliary care
    • Patients, requiring joint injections as part of palliative care
    • 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