SPEECH AND LANGUAGE THERAPY REFERRAL FORM

Name:
NHS number:
D.O.B: / Sex M/F
Address:
Post Code:
Tel No:
Alternative No:
Name of Carers:
G.P:
Language spoken at home:
Interpreter needed: Yes/No
Early Years Setting/School:
am/pm session? (please circle)
List other Professionals involved (provide name if known);
□ Audiology ______
□ Educational Psychologist ______
□ Education Welfare Officer ______
□ ENT ______
□ Family Support Worker ______
□ Health Visitor ______
□ Occupational Therapist ______
□ Physiotherapist ______
□ Portage ______
□ Other ______
CAF Completed: Yes/No
Child in Care: Yes/No
Known to Social Services: Yes/No
Referred or known to CDC: Yes/No
Previous referral to SLT: Yes/No
Date:

PLEASE COMPLETE ALL SECTIONS IN FULL OR THE

REFERRAL MAY BE RETURNED

Detail your concerns under the following headings
Attention and Listening
Understanding Language (e.g. instructions at home/in setting)
Use of spoken language (e.g. vocabulary, talking in sentences)
Social interaction (e.g. forming relationships with peers, appropriateness of interaction, play and imagination, repetitive behaviour etc)
Voice (e.g. hoarse voice)
Speech sounds (please see ‘Stages of typical speech sound development’ table attached before referring for speech sounds)
Fluency (e.g. the child has a stammer/stutter)
Additional needs (does the child have any additional needs? (e.g. physical, medical or learning needs)
Additional information e.g. impact on learning, behaviour and social relationships (please give information such as: EYFS Profile, P levels, NC levels, copies of any recent reports e.g. Educational Psychologist, Consultant/Specialist Teacher)
If referrer is an early years setting/school, please complete this section
What strategies have you already tried to support this child and how effective were they? (e.g. SLT resource packs such as Foundations for Understanding, narrative group, use of visual timetable, SEALs group etc.)
Has your setting accessed any SLT training? If yes, please provide details
Have you discussed this child at a link SLT meeting? YES/NO
What do you hope to gain from this referral?
School –
Parents –
Child/Young person (if appropriate) –

REFERRER DETAILS AND CONSENT:

Referrer’s Name: ...... Role: ......

Referrer’s Contact address: ......

......

......

Referrer’s Contact telephone number: ......

Referrer’s Signature: ………………………………………………………. Date: …………………..

Please tick to say you have discussed this referral with parent/carers & can confirm that they are ready, willing and able to attend an appointment 5

A person with parental responsibility must sign the form below to consent to the referral being made:

Signed: ...... Date: ......

*Please be aware that it will be your responsibility to attend all future appointments offered or your child will be discharged.

I have discussed this referral with the child/young person (if appropriate)

Child/young person’s signature: ……………………… Date: ……………….

If you would like any help completing this form or if you have any questions please contact:

The Speech and Language Therapy Team on: 0151 495 5024

or alternatively e-mail:

PLEASE RETURN TO

Speech and Language Therapy Department
Widnes Health Care Resource Centre
Oaks Place
Caldwell Road
Widnes
Cheshire
WA8 7GD
Tel: 0151 495 5024 / Fax: 0151 424 2692