Speech and Language Therapy Referral Form

SPEECH AND LANGUAGE THERAPY REFERRAL FORM

PRE SCHOOL CHILDREN

New referral Re-referral (Please provide name of previous therapist:. ……………………………………………….)

Child’s First Name:
/ Surname:
Parents/Carers Names: / Sex: M/F DOB:
NHS No:
Address:
Postcode: / Home Telephone:
Mobile: / Email:
Child’s Main Language: / Other Language(s):
Is an Interpreter Needed: Y/N / Ethnicity:
Setting: / Day/ times of attendance (please circle): / AM: Mon Tue Wed Thu Fri
PM: Mon Tue Wed Thu Fri
Safeguarding Plan / CAF: YES / NO / Code of Practice (If applicable): My Plan/My Plan+/EHCP
Medical Diagnosis:
REASON FOR REFERRAL:
What actions have you already taken to support this child’s speech and language needs?
What do you hope to achieve through making this referral to Speech & Language Therapy that has not been addressed through previous involvement or other sources of advice & information?
FOR RE-REFERRALS: Please add/ attach evidence of the actions you have already taken to support this child’s speech & language needs. THE REFERRAL WILL NOT BE ACCEPTED WITHOUT THIS EVIDENCE. E.g., visual timetable, extra support in class, small group work, etc.

Have any of the following professionals been involved? (Please attach copies of any reports).

Professional / Name / Professional / Name
□  Advisory Teaching Service / □  Occupational Therapist
□  Educational Psychologist / □  Health Visitor
□  Paediatrician / □  Family Support Workers
□  Audiology / □  Social Worker
□  Physiotherapist / □  Portage

Please find the child’s age and tick the difficulties that they are having.

2 YEARS:

□  Child uses only a few recognisable words (they do not have to be perfectly clear e.g. “do)

□  Child doesn’t understand simple sentences with one key word e.g. where’s the cup

□  Few or no attempts to communicate with familiar adults

2 ½ YEARS:

□  Child is using fewer than 50 recognisable words (they do not have to be perfectly clear e.g. “efa” for “elephant)

□  No spontaneous 2 word phrases e.g. “Daddy car” “Mummy gone.”

□  Poor or limited interaction e.g. no eye contact with adult

□  Not understanding simple instructions with 2 key words e.g. “where’s mummy’s nose?”

3 YEARS:

□  Child not using 2-3 word phrases e.g “Me want drink.” “Home now Mummy”

□  Consistently missing sounds from the beginning or end of words e.g. “-ar” for car, “be-“ for bed

□  Parents can rarely understand the child’s speech

□  Not understanding basic instructions e.g. “put the cup on the chair.”

3 ½ YEARS:

□  Child does not appear to understand concepts: big/little, on/under

□  Child not understanding simple question words (who, what, where) e.g. “where’s Grandma?”

□  Child is using fewer than 3-4 words in his/her sentences

□  Child is not using f or s sounds at all e.g. says tun instead of sun, knipe instead of knife

□  Unfamiliar adults can rarely understand the child’s speech

4+ YEARS

□  Child cannot understand more complex instructions e.g. “put the ball and car under the box”

□  Child is not using grammatical words or endings in sentences e.g. the, is, –ing, because etc

□  Child uses only key words in his/her sentences e.g. “me go shop”

□  Child consistently confuses k and g with t and d e,g, tup instead of cup, gaggy instead of daddy

□  Child’s speech is not easily understandable

OTHER:
□  Child has a persistent hoarse voice or voice loss (must have been seen by ENT first) / □  Child is stammering
□  Child has difficulty socialising and/ or playing/sharing with peers or adults / □  Child is reluctant or refusing to talk in certain situations although they are able to talk
□  Feeding difficulties / □  Other (please specify):
REFERRAL FOR THE FOLLOWING DIFFICULTIES IS NOT APPROPRIATE PRE-SCHOOL:
·  Difficulties using consonant blends e.g. spider, train, plate etc
·  Difficulties using sh, ch, j, l, r, th
·  LISPS: using th instead of s
Full Name of Referrer (PRINT): / Date:
Job Title: / Signature:
Address:
Contact Number: / Email address:
CONSENT FOR REFERRAL FROM PERSON WITH PARENTAL RESPONSIBILITY: I understand the reasons for this referral being made and consent to the information being shared with relevant professionals.
PRINT and sign:
PLEASE RETURN TO:
Speech & Language Therapy Service for Children, Independent Living Centre, Village Road, Cheltenham. GL51 0BY
Telephone: 0300 421 8937