Preschool Age - Speech and Language Therapy Referral

Please provide as much information as possible to avoid a delay in processing the referral. Incomplete forms will be returned to the referrer. For assistance in filling out form, please contact Speech and Language Therapy on 01208 834488

Child Details: (Or attach a copy of patient file)
Name of Child: / Date of Birth: / Sex:
Address: / NHS Number:
Tel Number:
Post Code: / Mobile Number:
Parents - / Mother: / Father:
School: / GP:
Address: / Surgery:
Home language:
Other Languages:
Contact:
Number: / Interpreter Required:
Child’s Ethnicity:
White British / ☐ / Mixed White/Black Caribbean / ☐ / Asian British Pakistani / ☐
Cornish / ☐ / Mixed White & Black African / ☐ / Asian British Bangladesh / ☐
White Irish / ☐ / Mixed White & Asian / ☐ / Any Other Asian Background / ☐
Any Other White Background / ☐ / Any Other Mixed Background / ☐ / Black British Caribbean / ☐
Black British African / ☐ / Any Other Black Background / ☐ / Any Other Ethnic Group / ☐
Chinese / ☐ / Asian British Indian / ☐
Consent: To be signed by the child’s parent or guardian
I give permission for this referral to be made and for the speech and language therapy service to assess & treat my child. I also consent to the sharing of information and reports about my child between the speech and language therapy service and other relevant professionals / services, in order for them to provide the most appropriate intervention.
Signed: / Name: / Date:
If you DO NOT wish to receive copies of reports about your child please tick: ☐
Verbal Consent: (Health Professionals)
The referrer has gained verbal consent for:
This referral to be made
The Speech and Language Therapist to assess & treat the child
The sharing of information between professionals and services who are part of the Early Help Hub response / ☐
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Referral Information

Referrer’s Details:
Name: / Designation:
Contact Address: / Contact Number:
Email Address
Date of Referral
Child’s Current Family & Social Situation:
Who lives at home with the child?
Parents: / Siblings: / Others:
Other significant adults or family members with regular contact?
Please provide any relevant details about the family or child (e.g. culture, traveller community, HM forces, ethnicity, learning or literacy needs, recent changes in circumstances, accessing short breaks etc).
Safeguarding: / Child In Need / ☐ / Child Protection Plan / ☐ / Other / ☐
Has a CAF / TAC / Early Support been initiated for this child? / If yes, give lead professional’s details:
Child’s Medical Information:
Details of any medical conditions, diagnoses or developmental delay (e.g. delayed milestones, learning difficulties, ASD, vision, hearing, asthma, allergies, epilepsy)
Date of last hearing test: / Outcome of last hearing test:
Details of any medication taken by the child:
Does the child experience frequent or recurrent ear, throat or chest infections? (Provide details about frequency & treatment received).
Reason for referral
What do you hope to achieve through making this referral to Speech & Language Therapy (see guidance) that has not been addressed through previous involvement with the SLT service or other sources of advice & information?
Child’s Education Information:
Teacher/Teaching assistant name if appropriate: / Year and class name: / ECHP in Place? (Y/N)
Attainment levels : Please describe
For all children of pre-school and school age please provide details of their current Early Years Foundation Stage, National Curriculum , P levels and EY/S levels – attach copies of recent assessment results or checklists & IEP if appropriate.

Speech, Language & Communication Needs

Reason for Referral
For Help Line please call 01208 834488 and leave your details.
Age of child / Reason for Referral / Y / Please describe
All Age ranges / Child has eating and drinking / swallowing difficulties / ☐
0 – 23 months / Referral ONLY by Paediatrician, Portage or Senior Area SENCO– with copy of recent report. You can contact the helpline to discuss your concerns initially. / ☐
24 – 35 months Do not refer if only unclear speech / Child has been stuttering / stammering for 2 months or more / ☐
Child is using less than 10 spoken words (count all words even if they are unclear e.g. gaga for Grandad) AND please tick if any of the following risk factors apply:
- Child does not copy sounds, actions or words e.g. animal sounds, actions in songs, “uh oh”, pointing to what they want to say.
- Has a delay in understanding spoken language e.g. does not point to body parts on request.
- Child has limited play skills e.g. does not make pretend tea, does not act out little scenes with toys.
- Child shows little or no interest in communicating with others e.g. limited eye contact or pointing.
- Limited change over time e.g. when a member of the health visiting team reviews the child’s progress after 3 months or more. / ☐ / Please list words they use:
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36 – 40 months / Child cannot follow a short verbal instruction / ☐
Child is only using single words or two-word sentences / ☐
Child has been stuttering / stammering for 2 months or more / ☐
Has unusual or obsessive interest in certain types of play (e.g. excessive spinning of toys) / ☐
Has poor social skills (e.g. difficulty initiating & playing with other children) AND uses limited eye contact & pointing / ☐
Parents not able to understand child most of the time / ☐ / How does the child say these words:
Cat / Man
Fish / Table
Lion / Sauce
Blue / Green
Spider / Chips
Dog / Sun
Fork / House
41 – 48 months / Child is not regularly using 4 – 5 word sentences / ☐
Others cannot understand what the child is saying (unclear speech)
/ ☐ / How does the child say these words:
Cat / Man
Fish / Table
Lion / Sauce
Blue / Green
Spider / Chips
Dog / Sun
Fork / House
Child is stuttering / stammering / ☐
Poor social skills, including:
-limited imaginative play
-repetitive behaviours
-poor eye contact
-difficulty turn-taking
-obsessive about certain topics
-difficulty maintaining conversation / ☐ / Please Specify:
Support already in place
For each area of difficulty please provide details of strategies and support that you have put in place to help the child already and comment on how successful they have been (this could include parent groups at the children’s centre, e.g. Toddler Talk, advice from your Health Visitor, educational psychologist, classroom based strategies, visual support etc.)
Current Situation:
Parents & referrer to rate where the child is now – please tick
(0 = not at all / never and 10 = extremely / always)
1 / How concerned are the child’s parents about his/her speech and language difficulties?
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2 / How concerned is the referrer about the child’s speech and language difficulties?
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3 / How much are the child’s communication difficulties affecting his/her ability to interact with / talk to / get along or play with others in everyday situations?
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4 / How much do you think the child’s speech or language difficulty is affecting their ability to access the curriculum, including Foundation Stage?
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5 / How often is the child becoming frustrated, angry or withdrawn due to their communication difficulty?
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6 / How aware is the child that he/she has a difficulty with communication?
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7 / How confident do the parents feel in supporting the child’s communication development?
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8 / How confident does the referrer (if teacher or education worker) feel in supporting the child’s communication development?
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Referrer’s checklist & signature
Have all sections been completed? / Have you included evidence of attainment levels?
Has consent been obtained? / Referrer’s signature:
Send this request to the Early Help Hub
Please state the service you are requesting in the subject box of your email. This will assist in the triaging of your request.
Telephone enquiries: 01872 322277 Monday to Thursday 8.45am to 5.15pm
Friday 8.45am to 4.45pm
Or visit the website www.cornwall.gov.uk/earlyhelphub