Speech and language therapy service referral form Adult Community CARE HOMES: Please DO NOT use this form. Use the Care Home referral form instead. Please do not print off this form. Fill in all fields and click 'Submit' at the bottom. If important information is missing, we may need to contact you before we can accept the referral. If you need help, please ring us on 0115 9512433. Patient Location Please tell us where the patient is now, to help us forward the referral to the right team. Where is the patient currently? Required Care Home or Nursing Home - if Yes, please stop and use the Care Home referral form instead Community Hospital Inpatient Ward - If Yes please enter Hospital and Ward below. In their own private residence. For Community Hospital Inpatient referrals - which hospital and ward is the patient on? Patient's details Full name Required Date of birth Required Address Address 1 Address 2 City State/Province Country United Kingdom Postal Code NHS number (if known) Patient contact details Home landline number Mobile phone number Which is their preferred number? Home Mobile phone Email address Does the patient need an interpreter? Yes No Which languages does the patient use / understand? Next of Kin (NoK) Please supply details of the patient's next of kin, if applicable. Next of Kin full name Relationship to patient Next of Kin phone number Lasting Power of Attorney (LPA) for health and wellbeing Please enter detail of person holding LPA if applicable. You MUST email dchst.SLTcentralreg@nhs.net with: the patient's name and DOB copies of court documents confirming LPA. LPA full name Relationship to patient The SLT service will need to see other health service records about the patient, and to share SLT records with other health services. Please tick if the patient does not want us to share their records. Patient consent to referral Has the patient or Attorney for Health and Wellbeing consented to this referral? Required The patient has consented to this referral The Attorney for Health and Wellbeing has consented to this referral The patient is unable to give consent If patient is unable to give consent, please give details: Medical details Patient's medical diagnosis and relevant medical history Please list any diagnosed allergies Appointment arrangements Can we email the patient personal information about them? (information may go astray) Yes No If yes, please state patient's email address. Can we leave messages mentioning speech and language therapy on the patient’s answerphone? Yes No Can we send the patient text messages? Yes No If yes, please state preferred mobile number: Can the patient attend clinic for an outpatient appointment? Yes No If no, please state why not: Can the patient do appointments by video? Yes No Are there any health and safety issues for professionals visiting the patient's home? Yes No If yes, please give details or give your contact number to discuss issues Reason for referral What is your main area of concern? Required Communication Eating, drinking, swallowing Both What are your specific concerns and what is the impact on the patient? Required What have you tried so far? Required What help do you want now from the SLT Service? Required If you have concerns about communication: Can the patient express a simple choice if supported to do so? Yes No Don't know Can the patient participate effectively in a simple conversation? Most of the time. Some of the time. Not at all. How is the communication need affecting the patient and their family / carers? If you have concerns about eating, drinking, swallowing: Does the patient cough or have difficulty when eating/drinking? Yes No If yes, is it .... Every meal Intermittently Are there concerns about weight loss? Yes No If yes, please state current weight: Please state weight one month ago (if available): Are there concerns about dehydration? Yes No Is there evidence of current or recurring chest infection? (Tick all that apply) Yes - current Yes - recurring No If yes, please give dates of all recent chest infections: What are the current recommendations for eating and drinking? Patient's home circumstances / social support Lives alone with no social care input Lives alone with care package Lives with family / partner Other Referrer details Referrer Name Required Referrer job title or role (if you are the patient, state 'patient') Required Referrer phone number Required Referrer work email address (We will send information by email where possible. We can only send information to a work email address.) Required Referrer work address Address 1 Address 2 City State/Province Country United Kingdom Postal Code Name and speciality of any consultants currently involved Any other professionals or teams involved About the patient Referrer: please ask the patient these questions if possible and complete the form, or support them to complete the questions themselves. Please do not assume answers based on the patient's presentation - always ask. We want to find out about the patient, so we care for them in the most helpful way. Their answers will also help us to plan our services better. If you want to know more about why we ask these questions, please ask us for a leaflet. You do not have to answer all the questions, but if you do, this will help us to meet the patient's needs more easily. We will keep this information confidential. Is the patient a carer? Yes No If the patient is a carer, provide them with the following information: Support for carers can be found here: www.carersinderbyshire.org.uk. If you need help accessing this information please ask. Derbyshire Carers Association 01773 833833 Does the patient have any of these disabilities or long-term conditions that impacts their daily life? (Tick all that apply) Emotional or behavioural difficulties Hearing difficulties Difficulties with manual dexterity (moving the hands) Difficulties with memory, concentration or ability to learn or understand Learning disability Autism Dementia Moving the body, arms or legs (mobility or gross motor difficulties) Personal, self-care or continence needs Progressive or long-term physical health needs (such as cancer, HIV, multiple sclerosis, epilepsy etc) Sight difficulties Speech, language or communication difficulties No disability or long-term condition The patient does not want to answer this question Please list any reasonable adjustments the patient needs to access services (e.g. wheelchair access, use of augmentative communication systems etc) What is the patient's ethnicity? White - British White - Irish White - any other White background Mixed - White and Black Caribbean Mixed - White and Black African Mixed - White and Asian Mixed - Any other mixed background Indian Pakistani Bangladeshi Any other Asian background Caribbean African Any other Black background Chinese Any other - please state below The patient does not want to answer Other ethnicity - please state below What is the patient's religion? Christian Muslim Hindu Jewish Sikh Buddhist Jain Baha'i Pagan Zoroastrian Any other religion No religion The patient does not want to answer this question What is the patient's sexual orientation? Heterosexual / Straight Gay or lesbian Bisexual Other The patient does not know or is not sure The patient does not want to answer this question What is the patient's marital status? Single Married / civil partnered Divorced / civil partnership dissolved Widowed / surviving civil partner Co-habiting Separated The patient does not want to answer this question What is the patient's gender? (Please ask them, do not assume based on how they present) Male Female Non-binary The patient does not want to answer this question Is the patient pregnant or have they given birth in the last 26 weeks? Yes - pregnant Yes - given birth in last 26 weeks No Not applicable The patient does not want to answer this question Does the patient need information in an accessible format, or support with communication, because of a disability or long-term condition? Yes No If yes, please describe what support the patient needs or uses (e.g. hearing aid, British Sign Language, signing, symbols, lip-reading, communication aid etc) Please state any spiritual needs the patient has Submit Return to speech and language therapy for adults
