Send this referral to:

West Suffolk: Paediatric Speech and Language Therapy, Child Health Centre, Hospital Road, Bury St. Edmunds Suffolk, IP33 3NDTel: 01284 775081

East Suffolk: Paediatric Speech and Language Therapy, St. Helen’s House, 571, Foxhall Road, Ipswich, Suffolk IP3 8LX Tel: 01473 321225

Suffolk

Community

Healthcare

Action

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Received @ CHC/SHH

INTEGRATED COMMUNITY PAEDIATRIC SERVICES: PAEDIATRIC SPEECH & LANGUAGE THERAPY

REFERRAL FORM (October 2015)

PLEASE COMPLETE ALL THE FOLLOWING INFORMATION ABOUT THE CHILD YOU WISH TO REFER. INCOMPLETE FORMS WILL BE RETURNED

Surname
Forename
Male/Female
Date of Birth
Address including postcode
Telephone numbers
GP
NHS number
Educational setting
Latest Hearing test: date & result
Family set up
Any Safeguarding issues? If yes please elaborate including name/contact details of relevant professionals
Bilingual/English as an additional language? Please say what the first language of the child is and/or is spoken in the home

Therapists are not permitted to see a child under the age of 16 without the consent of a parent or guardian. Please ensure that you discuss it with them and obtain their consent.

Your name- please print & sign
Designation
Contact address
Date

What is your main concern?Please describe the nature of the child’s difficulties in as much detail as possible and why you wish to refer to the service. Please state your concerns next to each heading with examples.

You may wish to use the criteria for referral checklist to help you decide.

Is there any family history of speech and language difficulties?
Attention & Listening: what level of support does the child need to attend/listen to an activity?
Speech: is the child’s speech unintelligible/can you state which sound(s) the child seems to have difficulty with?
Understanding of language: following instructions
Use of language: putting words together; grammar; sentence length etc)
Dos the child use any AAC strategies such as: gestures; signs; symbols; voice output communication aid?
Vocabulary- limited; how many words; type of words used?
Stammering: repeats part/whole words; gets stuck on words; child is aware; parents concerned?
Social skills/Interaction with others: how does the child interact with others?
Any other information we may need to know?

PLEASE ADD IN RELEVANT INFORMATION BELOW:

What input has been given by you to develop their communication skills?
If school age:Please enclose a recent school report/early years profile and copies of any recent reports/assessments carried out by educational professionals such as Educational Psychologist.
If he/she is on School Action/School action plus/has an IEP/ Statement, please attach copies.
What is their level of attainment e.g.: reading/spelling age/recent profile?
Any other professionals involved with the child?

ONLY FILL THIS SHEET OUT-If there are any concerns regarding eating/drinking– OTHERWISE NO NEED TO INCLUDE

Please describe the nature of the child’s feeding difficulty in as much detail as possible:
  1. Have there been concerns around failure to thrive? Is the child known to dietetics?

  1. Are there any developmental or social concerns that may impact on feeding?

  1. Has the child had a history of recurrent chest infections?

  1. Has the child had a history of reflux or significant vomiting?

  1. Is the child on any regular medication?

  1. Are any other professionals involved e.g. Physiotherapy, Occupational Therapy, Psychology, Paediatrician, Dietician

  1. Are there any concerns around communication development?

A service delivered by a partnership of

The Ipswich Hospital NHS Trust

Norfolk Community Health and Care NHS Trust

West Suffolk NHS Foundation Trust