Services for Childrenand Families

Children’s Speech and Language Therapy Service

School Age Referral Form

Send to: Speech and Language Therapy Admin, Coral House, 11 Longbow Close, Harlescott Lane, ShrewsburySY1 3GZ

Or Fax to: 01743 450801

Name of Child: ______Date of Birth: ______Age at Referral______

Address: ______

NHS Number (if known)______Sex M/F Ethnicity______

Parent/Carer Name(s):______

Parent/Carer Address (If Different)______

*Telephone Number______Preferred Contact Times______

*Telephone Contact Details –The first contact with the parent/carer(s) may be by telephone.

Please provide a current daytime telephone number

Home Language(s) ______Interpreter needed? Parent Yes  No□

Child Yes  No□

Referred By______Professional/ Relationship Child______

Contact Number/Address______

GP Address & Contact Name/Number______

Consultants Address & Contact Number______

Other Professionals Involved______CAF/EHAF Yes  No□

SENCO______Early Years/ School______

Does the parent/carer consent to this referral and an initial assessment if required?Yes /No

Is the child aware of this referral?Yes/No

Is this child known to Social Care? –Child in Care? Yes □ No □

Child Protection Plan? Yes □ No □

Child with Disabilities Plan? Yes □ No □

Date of Referral______Signature______

For Service Use Only

Date Referral Received / Caseload
Client Registration Number / Added to Waiting List

A. This first section is about what support you are looking for, the support available in school and/or at home and the child’s wider learning needs

1. Please explain why you have decided to make a referral to the Speech and Language Therapy Service including what you would like the service to provide
Have you already asked a Speech & Language Therapist who visits your school for their opinion about this child? What was the recommendation?

If this child has been seen by an LSAT or EP, please attachtheir most recent report to this to the referral. Please seek parental permission to share these reports with us. Our usual practice is to ask you to follow at least one specific piece of advice related to SLCN from these reports for two terms before considering referring to SLT for further detailed assessment. Please detail which of these strategies you have implemented in the box below.

B. This section is about your identification of this child’s specific SLCN

Please answer the questions below, to help us understand the child’s profile. (Some children may have difficulties in more than one area). We triage all referrals to ensure they are appropriate to go forward for a SLT assessment. The information you provide not only ensures we make the right decision it enables us to target our assessment to the areas of need you have identified.

Areas of need / Yes/No / If yes please share your observations
1. Does this child have difficulties attending to tasks within the classroom e.g. is he/she easily distracted or flits between activities?
2. Does this child have difficulties with understanding spoken language e.g. following instructions in the classroom?
3. Have you noticed if this child has any specific short term auditory memory difficulties? e.g. digit span, repeating sentences
Areas of need / Y/N / If yes please share your observations
4. Does this child have difficulties with spoken language e.g. a limited vocabulary, problems with grammar or sentence structure?
5. Does this child have difficulty finding the words he / she needs e.g. are there long pauses when responding, do they use the wrong label e.g. ‘chair instead of table’ or talk around a subject
6. Does this child frequently switch topics in conversation, talk repetitively about particular topics, take comments literally?
7. How does this child interact with his/her peer group? E.g. is his or her style of interaction appropriate
8. Does this child have a speech sound difficulty e.g. has problems producing certain sounds and/or substitutes some sounds for others e.g. uses t’ instead of ‘k’.
9. Does this child have difficulty making themselves understood?
10. Does this child have difficulties with stammering?
11. How does this child respond to initial communication breakdown? (e.g. persists, becomes frustrated / angry, gives up, becomes withdrawn – does the child have any strategies to be able to manage this
12. At school does this child show any difficulties with behaviour that you think may be related to SLCN?
What additional information would this child’s parents like to share with us?

C. This section is about where and how it will be best to provide SLT support if it is required after the assessment

  1. Children are usually offered a clinic appointment for initial assessment. Would you foresee any difficulties with regard to attendance (e.g. transport / childcare difficulties)
/ YES/NO
  1. Please indicate if you would like to be informed of the date of the child’s initial appointment
/ YES /NO

Thank you for taking the time to fill out this form

Mike Ridley –Chairman
Jan Ditheridge – Chief Executive / “We welcome your Friends and Family feedback. You can do this by following the link by filling in a feedback form available at clinics or from your health care professional.”
Shropshire Community Health NHS Trust
Services for Children and Families
SLT School Aged Referral Form/SLT/Masters/Referral Forms/Review date May 2016
Amended version 1 /

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