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ADULT SPEECH & LANGUAGE THERAPYSERVICE - COMMUNITY REFERRAL FORM
Thank you for referring to the Community Adult Speech and Language Therapy Service (18 years+).
Please complete the following pages with as much information as possible
ALL RELEVANT SECTIONS MUST BE COMPLETED (incomplete referrals will be returned)
Please note that currently we do notaccept referrals for communication or swallowing difficulties that result from the following conditions in isolation: Developmental disorders that continue into adulthood (including dysfluency/stammering), Mental Health disorders, Chronic cough, and Facial Palsy
PERSON BEING REFERRED
Name of person:
NHS number:
Address:
Presently situated at: Home St. Peter’s ward Braintree ward
OTHER (Give details):
______
REFERRER DETAILS
Name:
Job title:
Fullcontact address and phone number:
______
MEDICAL BACKGROUND
Relevant diagnosis and past medical history:
Relevant medication:
SWALLOWING REFERRALS ONLY:
Has the individual had a chest infection in the last 6 months? Yes No
Has the individual been seen by this service before? Yes No
If yes, are there concerns that the existing guidelines are Yes No
no longer appropriate?
Current diet and fluid consistencies (please state):
Reason for referral to service at this time (Please mark as appropriate):
New episodes of coughing / choking with fluids Re-current chest infections / aspiration
New episodes of coughing / choking with food Reduced ability to manage secretions
Exacerbation of pre-existing swallow difficulties Food/residues sticking in throat
Other (please detail):
How long have the symptoms been occurring?
Have there been any related investigations (e.g. Ba swallow / OGD)?
VIDEOFLUOROSCOPY
Videofluoroscopymay be considered to help inform the management of swallowing disorders. Please note that SLT’s are now non-medical referrers for this procedure and GP referral is no longer essential. Please indicate below if you know of any contraindications to this procedure for the individual being referred. (E.g. Recent significant heart operation or extensive exposure to previous radiological investigations).
No contraindications known
Contraindications to be considered (please detail):
*If you are not a GP / medical referrer, please check with the individual’s GP about any known contraindications to videofluoroscopy BEFORE submitting this referral form
VOICE REFERRALS ONLY:
Has the patient had an ENT examination within the last 6 months?
Yes Report must be attached to referral
No Referral must be made to ENT initially
COMMUNICATION REFERRALS ONLY:
SPEECH LANGUAGE
Very quiet Difficulties finding words
Imprecise / slurred Uses wrong words /wrong sounds in words
Very slow/very fast Appears to use nonsense words or sentences
Difficulty reading
Other (describe): Difficulties with writing
Difficulty understanding spoken language
Other (describe):
SOCIABILITY AND PREVIOUS COMMUNICATION FUNCTIONING
______
LEVEL OF CONCERN
______
Please return this form to:Adult Speech and Language Therapy Department,
St. Peter’s Hospital, Spital Road, Maldon, Essex, CM9 6EG.Fax to: 01621 727243 OR submit the referral via Systmone