Please complete as much information as possible; if you would like to discuss any aspect of your referral, please contact North East Drive Mobility Tel:  0191 2875090

If you are referring from CNTW NHS Foundation Trust PLEASE NOTE: North East Drive Mobility does not have access to Mental Health records held by CNTW on RIO so please enclose any information that is appropriate for the referral. 

Please note powered chair and mobility scooter assessments can only be carried out at our Newcastle Centre.
 

Personal details

Required
Required
Required
Required
Required
Required
Client consents to referral Required

Referrer details

Required
Required
Required

GP details

Required
Required
Required

Medical history and current functioning

Required
Required
Required
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Required
Do they currently have
Are there any issues you are aware of relating to the following?
Driving Experience

Powered wheelchair and mobility scooter

What is the client interested in trying? Required
Required
Where will it be used? Required
Will it be transported by car?
Is there a charging point in this location?
Ability to control powered chair
Will the client be assisted by a carer when using the chair or scooter? Required

Other details

Is an interpreter required?
Required