If the Referral Is Incomplete It Will Be Returned for Full Completion

Adult Speech and Language TherapyReferral

Please completeALL fields below. This information willbe used to triage the referral and assign a priority ratingscale.

If the referral is incomplete it will be returned for full completion.

Please fax, post or email this form to the department. Thank you.

Name: / Name of referrer and role:
Address and contact number of referrer:
Date of Birth:
NHS Number:
Current Address & phone no. / GP Name and Practice:
Usual Address & phone no. / Regarding an appointment we should contact:
Contact Number:
Person can attend outpatient clinic Yes  No 
If living at home, the person:
Lives alone 
Lives with family / live-in carer 
Lives alone with carers visiting:
Once daily  2 x daily 3 x daily 4 x  daily
Other  ……………………………………………… / Diagnosis:
Date of onset of swallow/communication problems:
Has it got worse since Yes  No 
Has the person consented to the referral:
Yes  No  Referral in Best Interest 
Medical History: (or attach GP summary) / Medication: (or attach list)
Communication assessment required Yes  (complete boxes below) No  / Yes / No / Unknown
Has there been a new change to their communication?
Are they highly frustrated or anxious about their communication needs?
Can they consistently make their basic needs known?
Can they call for help if needed?
Can they communicate with family/friends adequately
Can they talk on the phone
Can they communicate with staff in shops
Do their communication difficulties prevent them working
Please describe the communication difficulty:
Swallow assessment required Yes  (complete boxes below) No  / Yes / No / Unknown
Full assistance is needed with food/drink
Full assistance is needed with mouth/oral care
They are mobile (walking)
Their health is likely to deteriorate very rapidly (next few days)
Their health is likely to deteriorate in next few weeks
They have a diagnosis of reflux
They have a chest infection now
They have frequent/recurrent chest infections
They have had a chest infection in the last two months
There has been recent unintentional weight loss
They are known to the Dietitian and are being monitored
Current weight: / MUST score and date:
The person : / Always / Daily / Weekly / Rarely / Never / Unknown
Coughs during or after meals / snacks
Coughs during or after drinks
Coughs on their own secretions / saliva
Experiences choking episodes (ie blocked airway)
Has drooling of saliva / food / fluid
Takes a very long time to eat and drink
Eats too quickly
Holds food/drink in their mouth
Shows pain or discomfort when swallowing
Refuses food and / or drink
Is at very high risk of dehydration as drinks too little
Has started having problems swallowing tablets
Person/carer is very anxious about swallowing
Current intake:
Food: Normal Fork-mashable Pre-mashed Thick Puree Thin Puree Other:
Drink: Normal Slightly thickened Thickened to Stage 1 2 3
Tube feeding only Tube feeding and oral intake (specify)
For those known to be feeding at high risk of aspiration : / Yes / No / Unknown
Food/fluid recommendations are documented and being followed
Advance care plans are in place
The person has capacity re food and fluid choices
The person been seen by a speech and language therapist before
The recommendations for swallowing/communication were……………………………………………………
………………………………………………………………………………………………………………………....
…………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………
Your concerns / any other information you feel is relevant (eg current ill health impacting, cultural considerations etc)

Referrer signature: Date:

Triage documentation

T:\SLT_Adults_SCT\Clinical\B&H\Triage docs\B&H NEWReferral form 3 Nov 2016.docx