Physiotherapy Self-referral Form

The risk to the public for Coronavirus has now been updated to High. The government is now moving from the containment phase into the delay phase: aimed at delaying the spread of coronavirus rather than containing it.

In line with this, we ask that all patients contact their preferred physiotherapy provider in the first instance by telephone, and that most urgent cases will be treated as priority. The full contact list is available on the CCG website:

Please note that some physiotherapy practices may have taken the decision to close until further notice, and therefore you may need to contact an alternative provider to that of the one you may usually see.

Please also note that Everybody Sport and Recreation have taken the decision to close their Leisure Centres until at least the end of April and therefore are unable to offer the ESCAPE-Pain Programme for Hips, Knees, or Back pain at this time.

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.