SPEECH & LANGUAGE THERAPY REFERRAL FORM FOR SCHOOLS, USING RAG RATING

Name of Child D.O.B:
Address: NHS No:
Telephone No: G.P:
Name of carer and relationship to child:
Date carer permission given for referral:
Name of School:
Address:
Referrer: Position/Title:
Telephone no: Date of Referral:
First language: Is an interpreter required?: Y / N *
Ethnicity:
First language screen completed: Y / N *
Does the child have a Statement? Y / N *
Is this a Looked After Child? Y/ N * Named Social Worker : ______Telephone No:______
Other Agencies Involved:
Edwin Lobo Centre / Child Development Centre / Early Years Service / Audiology / Educational Psychology /
Eye Service / Child & Family / Social Services / SCD / Learning Support / Other (Please specify)
Please enclose copies of reports from any of the above agencies. Please also attach recent IEPs/observations.
* Delete as appropriate

Please only refer the child if his / her speech, language or communication needs fall within the RED section of the RAG rating, according to the training which your staff members have received. Please outline your concerns under each heading below, giving examples and as much detail as possible.

P.T.O….

Attention and Listening
Concerns:
Steps you have taken, and any strategies you have used, to support the pupil
Understanding of Spoken Language
Concerns:
Steps you have taken, and any strategies you have used, to support the pupil
Use of Spoken language
Concerns:
Steps you have taken, and any strategies you have used, to support the pupil
Speech Sounds
Concerns:
Steps you have taken, and any strategies you have used, to support the pupil
Stammering (Dysfluency) – eg is the pupil repeating initial sounds / whole words?
Voice e.g. Does the pupil have any problems with his / her voice?
Social Skills - please describe any concerns you have about the pupil’s social interaction
Other Abilities
Parental concerns/comments

Thank you for completing this form. The amount of information and detail included will expedite the referral process and ensure that only appropriate referrals are accepted.

Please send this form to:

Angela Benedito, Single Point of Access Administrator, Speech and Language Therapy, Florence Ball House, Bedford Health Village, 3 Kimbolton Road, Bedford,MK40 2NT

Tel No: 01234 310699