Speech and Language Therapy

Speech and Language Therapy

Pre-involvement Information

To be completed by the classteacher or SENCO. This information will help the Speech and Language Therapist to:

·  Fully assess the child’s speech and language abilities (target assessment to critical areas).

·  Understand the child’s progress with the curriculum.

·  Provide information relevant to school’s concerns.

Child’s name:______DOB:______

Address: ______

Home Tel: ______Mobile Tel: ______

Email (parents):______

School and name of SENCO: ______

Reason(s) for referral (please tick)
Understanding language □ Use of language □ Clarity of speech □
Stammering □ Social interaction □ Attention and listening □

Please describe the child’s abilities and areas of difficulty under the following headings:

Speech: (e.g. clarity, problems with particular sounds)
Verbal Comprehension: (e.g. listening, following instructions, understanding concepts and ideas)
Verbal reasoning/problem solving/critical thinking: (e.g. responding to wh-questions, understanding cause and effect, making predictions)
Social skills: (e.g. interactions, friendships, behaviour)
Literacy skills:
Challenging curriculum areas: (comment on abilities in any areas not covered above)
Areas of greatest concern:
1.
2.
3.
Desired outcome from assessment (e.g. diagnosis, pre-school strategies, support with IEP planning, programme)
Support available within the school to support an individual programme:
Is there a reason this family would find it difficult to book and attend an appointment? If yes, why?
Consent: Yes No
I give permission for other professionals to be contacted about this
referral. This includes school/nursery. □ □
I give permission for the Speech and Language Therapist to
assess my child in school and liaise with teaching staff. □ □
I give permission for the Speech and Language Therapist to □ □
leave text, or telephone messages regarding appointments.
I give permission for the SLT to send me emails about my child □ □
Parent/Carer signature……………………………… Date: …………………………….

REFERER DETAILS:

Name / Role
Address / Telephone
Email

PLEASE RETURN WITH THE SARF REFERRAL. REFERRALS WILL NOT BE PROCESSED UNLESS ALL THE PAPERWORK IS COMPLETED.

Return to:

Speech and Language Therapy Department

Sale Waterside, 2nd Floor, Waterside House, Waterside Plaza, Sale M33 7ZF