Speech and language therapy service referral form Children Please do not print off this form. Fill in all fields below and click 'Submit' at the bottom. If important information is missing, we may need to contact you before we can accept the referral. In the form below, 'child' refers to people under 18. 'Young person' refers to people between 18 and 25. If you need help, please ring us on 0115 9512433. Child / young person's details Child / young person's full name Required Date of birth Required Sex of child Required Male Female Unspecified NHS number (if known) Address Address 1 Address 2 City State/Province Country United Kingdom Postal Code Consent for referral For under 18s, please tick yes below to confirm that parents / legal guardian are aware of the information in this form and consent to the following: The SLT can contact other professionals about the child / young person's needs (e.g. school staff, health visitor). The SLT can see other health records about the child / young person to gather information about their needs. The SLT can share the child / young person's SLT record with other health services who are providing care. The child / young person's health records may be audited for quality assurance. A manager may attend occasional appointments for quality assurance. Student SLTs may attend appointments. Please give details if parents do not want any of these to happen Parent / legal guardian consents to this referral Required Yes Young person is over 18, has capacity and has given their own consent If consent not given for any of the above, please give details: Referral details You must discuss the child / young person's needs with one of our SLTs before making a referral (see Contact Us section for how to get in touch). If they agree to referral, you must enter the unique reference number they give you below. You do not need to discuss with us referrals for: eating/drinking, stammering or Autism assessment. Please enter the unique reference number the SLT gave you. Referrer name Required Referrer job title or relationship to patient (If you are the patient, state 'Patient'. If a relative, state your relationship.) Required Referrer phone number Required Referrer work email address (We will send information by email where possible. We cannot send information to a personal email unless you are the patient or parent). Required Referrer work address (if you are the patient/parent, add your home address). Address 1 Address 2 City State/Province Country United Kingdom Postal Code This referral is for (tick all that apply): Required Eating, drinking or swallowing PAEDIATRICIANS / CLINICAL PSYCHOLOGISTS ONLY: Autism MDT assessment Stammering (stuttering). PLEASE ANSWER STAMMERING QUESTIONS AT END OF FORM Speech sounds (articulation, pronunciation) Language (words, sentences, understanding) Social communication (social interaction, conversation skills etc) Voice (hoarse, crackly, losing voice) What are your specific concerns? (Give examples if you can) Required What have you tried so far? (Please refer to Graduated Response if child is at school/nursery) Required What help do you want now from the SLT service? Required What is your main area of concern at the moment - what would you like to deal with first? Required Are there any other learning needs, concerns or diagnoses? Required Concerns about wider learning / developmental delay Diagnosed learning disability / intellectual impairment Diagnosed Autism Referred for Autism assessment Diagnosed Attention Deficit Hyperactivity Disorder (ADHD) Referred for ADHD assessment Any other concerns, needs or diagnoses. (Give details below) No other concerns, needs or diagnoses If any other needs, please give details: Dates of any previous SLT input (NHS or private), and recommendations given. Family contact details For under 18s or those with care needs, please give parent/guardian's details. For over 18s you may give the young person's own contact details if appropriate. Main parent or carer's full name Relationship to child / young person Home landline number Parent / guardian's mobile number Young person's mobile number (over 18s only) Which is the preferred number? Home landline Mobile phone Young person's mobile phone (over 18s only) What is the child / young person's main language? Required Other languages spoken/understood by the family Does the child / young person need an interpreter for appointments? Required Yes No Do the parents need an interpreter for appointments? Required Yes No If interpreter needed, which is the preferred language? Appointment arrangements If patient is over 18 and has capacity, you may give their consent and details Can we email parents about their child? (information may go astray) Yes No If yes, please state preferred email address. Can we leave answerphone messages mentioning speech and language therapy? (Messages may be overheard) Yes No Can we send parents text messages? Yes No If yes, please state preferred mobile number: Can we visit the child at school/nursery at short notice, without specific parent consent each time? Yes No Any other professionals or teams involved Education setting Does the child / young person attend an education setting? (Nursery/pre-school, school, college, PRU etc) Required Yes No Name of setting Name of SENCo: Setting address Address 1 Address 2 City State/Province Country United Kingdom Postal Code Days child / young person attends (for each day state am, pm or whole day) Please ensure the setting's SENCo is aware of this referral and tick 'yes' to confirm Yes Important child / young person information Allergies or sensitivities: Required Does the child have an EHCP? Required Yes No Application / assessment underway Who lives with the child? (State names and relationship to child) Required Other parents, carers or siblings who don't live in the home: Name and details of people with parental responsibility (including address and contact number if different to child's home address) Is the child Looked After by the Local Authority? Required Subject to Care Order In foster care Under special guardianship Other arrangement - please give details below Not Looked After If Looked After, please give Social Worker name and contact number: Please give full details of any Care Orders or Looked After arrangements, including any adults who must not have contact: Are there any health and safety issues for professionals visiting the home? (E.g. pets, smoking, weapons, multiple occupancy dwelling) Required Yes No If yes, give full details below. Is the child a Young Carer? (Do they look after an ill or disabled family member (including those with mental ill health or substance misuse), with responsibilities inappropriate to their age?) Required Yes No If yes, please give full details: Stammering referrals only: More Information needed Please answer the questions below before submitting a referral for stammering. If you are NOT referring for stammering, you can skip to the Submit button at the end. Stammering is a neurological condition that makes it physically hard to speak. Someone who stammers will repeat, prolong or get stuck on sounds or words. There might also be signs of tension or movements (like forcing sounds out, foot tapping, eye-blinking or head movements) as the person struggles to get the word out. ‘Stammering’ and ‘stuttering’ mean the same thing. The word ‘dysfluency’ covers a range of speech behaviours such as hesitations, pauses, revisions and phrase repetitions. These may occur in children who stammer (alongside their core stammering), but are also often seen in preschool children learning to talk or in children who have difficulties with language processing and organisation. If you do not tick any of the boxes below, the child may not have a stammer. Please talk to us before referring. What does the child / young person do when they stammer? (Tick all that apply) Repeat whole words e.g. but but but Repeat parts of words e.g. b-b-b-but Stretch sounds out e.g. mmmmmmum Get stuck and nothing comes out Give up on trying Anything else (e.g. face or body movements) If 'Anything else', what do they do? Do you think the child is aware of the stammer? Yes No If yes, how do you know? (Tick all that apply) They show frustration when they speak They seem to avoid speaking in class and offer minimal information They change their words They give up or make comments such as ‘I can’t say it’ Anything else If anything else, please describe: When did the stammering start? Has it changed since then? Yes No If 'Yes', how has it changed? When does the child / young person stammer most? When do they stammer the least? What seems to affect it? E.g. tiredness, certain emotions, talking under pressure (e.g. in front of class or in a group) Do they ever get teased about it? Yes No Do any other family members stammer, or have they done in the past? Yes No If 'Yes', please give details Submit
