Request for Speech and Language Therapy

Child/Young Person’s details:

First and surname / D.O.B / School/setting / Year
Class / Gender
Home address / Parent/Carer(s) names
Phone number(s) and email address
Home language(s)

Reason for Speech and Language Therapy?

Please indicate the needs of your child or young person and the outcomes you hope for as a result of Speech and Language Therapy involvement.
What are your concerns? When were these first noticed? Has there been progress or deterioration?

Who else is involved? e.g. other professionals and services.

Does your child have a Statement or Education, Health and Care Plan? / YES / NO
Has there been previous Speech and Language Therapy involvement? / YES / NO

Please attach additional documentation that will be useful for the Speech and Language Therapist to plan their involvement e.g. Reports, I.E.P Targets, One Page Profiles.

Background information:

  1. Has your child’s hearing been tested?Yes  No Date completed? ______

Results of the hearing test:

 Hearing within normal limits  Hearing loss  Further testing required

  1. Have any family members had any speech, language, hearing problems or learning difficulties? Please describe if so.______

______

  1. What age did your child meet these milestones? (Please write their age or tick one of the 3 boxes.)

Age / Earlier than peers / Same time as peers / Later than peers
Sitting
Crawling
Walking
Toilet trained
Babbling
First word
Joining words together
  1. Is there anything significant we should know about your child’s medical history? ______

______

  1. Has your child had any of the following?

Frequent coldsSeizuresSnoringMouth BreathingSleeping ProblemsEar Infections  Surgery  Hospitalisations Other: ______

If so, please give information: ______

  1. Are there or have there been any feeding problems, e.g. problems with sucking, swallowing, drooling, chewing etc.? ______

Parent / Carer permission

  • I confirm that I have parental responsibility.
  • I give permission for the Speech & Language Therapist to become involved in supporting my child.
  • I understand that if the Speech & Language Therapist becomes involved information will be shared in accordance with the Data Protection Act and may be shared with other agencies/professionals where appropriate.

Parent/Carer signature: ...... Name (printed): ………………………………….

Date: …………………………

Please send this document securely to our Speech and Language Therapy team:

Schools’ Choice, Endeavour House, 8 Russell Road, Ipswich, Suffolk, IP1 2BX

or by email: