SPEECH & LANGUAGE THERAPY REFERRAL FORM
FOR ADULTS
Please return this completed form to the Central Booking Office.
By Fax : 02476 961560
Or by post: Patient Access & Booking, Central Booking Office, Paybody Building, City of
Coventry Health Centre, Stoney Stanton Road, Coventry CV1 4FS.
DETAILS OF THE PERSON BEING REFERRED
First name:
Surname:
Date of birth:
M/F
NHS Number:
Ethnic origin:
Language(s)
spoken:
Do they need and
interpreter?
Y /N
Full address: _____________________________________________________________
____________________________________________ Post Code: _________________
Telephone number (landline):
0247
Mobile telephone number:
Has the person consented to the
appointment?
Y/ N
Medical history: Please tick or circle
Can this person attend an outpatient
appointment?
Y / N
THE PERSON YOU ARE REFERRING
MUST HAVE A COVENTRY GP
CVA (stroke)Date(s) of CVA(s)___________
COPD / Dementia / Head injury /
Huntington’s Disease / MND / Multiple
Sclerosis/ Parkinson’s Disease
Name of GP: Dr
Address:
Other:
Telephone number:
Fax number:
Are any other health professionals involved? Other information you feel is important
Please tick or circle
for us to know.
Physiotherapy / Psychology /Occupational
Eg- risk issues
Therapy / Dietitian / Community NeuroRehabilitation Team / PD Nurses / COPD Team/
Physiotherapy/ Other:
REFERRER’S DETAILS
NB: A qualified health professional’s signature is required for swallowing referrals
Name of the person making this referral:
Position/title:
Address for correspondence:
Telephone number:
Referrer’s Signature:
Date:
IS THIS PERSON ON AN END OF LIFE PATHWAY?
Y/N
Please look at the questions below and complete the sections that are relevant to your /the
client’s difficulties. Please give as much information as you can. Thank you.
QUESTIONS ABOUT SWALLOWING
If the referral is for a swallowing assessment it must be made by a qualified health professional
Y/ N Comments/details
Does the person cough or choke when they
are eating and/ or drinking?
Have you noticed;




Eg How often? On food/drinks/both?
Swallowing seems effortful?
Refusing food or drink?
Food or drink falling out of the mouth?
Person needs more than 2 swallows for each
mouthful?
Meal times are taking longer?

Does this person have a history of chest
infections?
 How many chest infections have they had
in the last 12 months?
 Have these chest infections resulted in
hospital admission/s?
Does the person have thickener/a powder put
in their drinks to make them thicker?
Does the person eat normal food?
If not, what foods are they eating?
Is this person losing weight?
Does this person need help with eating and
drinking?
Does this person have difficulties taking
tablets?
QUESTIONS ABOUT COMMUNICATION
Voice
Does the person have problems with their
voice?
Stammer/stutter
Does the person have a stammer/stutter?
Language
Does the person struggle to:
 find the right words to say or write down?
 understand what people say to them?
Speech/ speaking
Does the person have problems with:
speaking clearly?
speaking loudly enough for people to hear?
OTHER
Does the difficulty impact on their/your ability
to work?
What is the person’s job/role?
Has there been a rapid change in their
speech and /or language recently?
Does the person wish to retrain their voice as
part of a gender re-assignment process?
If yes, how thick do the drinks need to
be?
Stage 1 / 2 / 3 / not sure
Pureed food? Food that is soft enough to be
mashed? What is difficult for them to eat?
How much weight have they lost?
Over what period?
If yes, referral must be made by ENT, or the
ENT clinic letter requesting SLT input be sent
with this referral.
Please fax/post both sides of this completed form to the number/address overleaf