Referral for Speech Language Therapy Service

Adult Community Team

Please complete all sections FULLY. Incomplete or illegible forms will be returned to the referrer and will result in a delay in the person being seen.

Patient Personal Details
Name:______
Date of Birth:______
NHS Number:______
Address:______
______
Post Code: ______
Is this address: Temporary/Permanent?
Contact Telephone Numbers:______
Can the person attend an outpatient appointment? YES / NO / Male/Female
Next of Kin: ______
Relationship to person: ______
Telephone Numbers:
Landline: ______
Mobile: ______
Other: ______
Who is the main contact for SLT to
call?______
GP Details
GP Name: ______
GP Address: ______
GP Telephone Number: ______Fax Number: ______
Reason for Referral (Tick ALL that apply)
Swallowing Assessment / Communication Assessment
Medical History
Primary Diagnosis: ______Date of Diagnosis if known: ______
Other Medical History:______
______
Is the patient’s condition: Stable  Improving  Deteriorating: Slowly  Rapidly 
Social Details
Does the person live: AloneWith spouseWith family
Residential HomeNursing HomeNursing Home (Residential Bed
Sheltered Accommodation/ Supported Living
Other (Please specify): ______
If for domiciliary visits, any known lone worker risk? ______
Patient Name: / DOB: / NHS No:
Communication – Please complete for ALL referrals
How does the patient currently communicate?
Is the patient able to understand what is being said to them?
Any other information/observations regarding the patient’s communication?
Does patient require an interpreter?
Swallowing – Please complete if you are referring for a swallowing assessment?
What is the patient’s current eating and drinking regime?
 Oral (Please detail below)  PEG  NG tube
FLUIDS:
Thin fluids
Naturally Thick/Slightly thickened fluids (1 scoop/200mls)
Syrup consistency thickened fluids (1.5 scoops/200mls)
Custard consistency thickened fluids (2 scoops/200mls)
Pudding consistency thickened fluids 2.5-3 scoops/200mls)
No oral fluids – s/c or IV fluids / DIET:
Normal
Normal diet, avoiding high risk foods
Fork-Mashable Diet (E)
Pre-Mashed diet (D)
Thick Puree Diet (C)
Thin Puree diet (B)
No oral diet
Does the patient show signs of aspiration during or after eating and/or drinking?
Eating Drinking
 Every time  Every time
 Daily  Daily
 Weekly  Weekly
 Occasionally  Occasionally
 Never  Never / Any other comments regarding eating and/or drinking and current diet/fluids?
e.g. Any patterns? Does coughing/choking occur more often with certain consistencies? Preferences? Any changes you have made to diet/fluids?
Does the person have a history of chest infections?
Yes/No If Yes, When?
Do they have a chest infection now? Yes/No
If Yes, prescribed antibiotics Yes/No / Is the person losing weight? Yes/No
Is the person known to the dietitians? Yes/No
Has the patient consented to this referral: Yes No Unable to
PLEASE RETURN THIS FORM TO:
Community Team:(Home visits, including nursing and residential Homes)
Speech Language Therapy, Highfield Centre, Victoria Central, Mill Lane, CH44 5UF
Fax: 0151 514 2323 Tel: 0151 514 2334 / Outpatients:
Speech Language Therapy, Arrowe Park Hospital, Arrowe Park Road, Upton CH49 5PE
Fax: 0151 604 7544 Tel: 0151 604 7714
Referrer Information
Name of referrer: ______Designation & Base: ______
Signature of referrer: ______Contact Details: ______

Referral for Speech Language Therapy Community Teams Aug 2014 v1.doc Page 2 of 2