CONFIDENTIAL
Speech and Language Therapy Dept
Sue Nicholls Centre, Manor House
Bierton Road
AYLESBURY
Buckinghamshire
HP20 1EG
 01865 901404
Speech and Language Therapy Dept
Oakridge Centre
240 Desborough Road
HIGH WYCOMBE
Buckinghamshire
HP11 2QR
 01865 901442
SCHOOL AGED CHILDREN’S SPEECH & LANGUAGE THERAPY REFERRAL
& SETTING QUESTIONNAIRE
Child’s Surname
Date of Birth
First Name
/
/
Male  Female 
Re-Referral: Yes 
No

NHS no:
Address
Postcode
Email address:
 home
 mobile
Child’s School

SENCO (print)
Class Teacher (print)
Link Therapist
Discussed with Link Therapist
Language spoken at home
Interpreter required for Parent Yes 
No

Ethnic Origin (if known)
Interpreter required for Child
No


Yes 
Please note that the Speech & Language Therapy Service will NOT be able to discuss any child before
the referrer has obtained parental consent and all sections of this form are completed.
Parent/Guardian’s signature ______________________________ Date ____________________
(required in all cases)
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School Aged Referral - May 2015
CONFIDENTIAL
USEFUL CONTACT NUMBERS
GP
Surgery

Educational Psychologist
Paediatrician
ENT Consultant
Social Worker
Occupational Therapist
Physiotherapist
Other Speech and Language Therapists (incl Private)

CAMHS
Other (please specify)
PLEASE TICK ALL RELEVANT BOXES
1. Who is concerned about the child’s communication?
Parent/Guardian

GP

School staff
2. Indicate the current areas of concern :
No Concern
 Pronunciation

 Understanding of instructions/questions 
 Putting sentences together

 Grammar

 Limited Vocabulary

 Attention and listening

 Play skills

 Interaction with peers

 Interaction with adults

 Stammering

 Dribbling

 Feeding


Other (please specify) ____________________
Concern












Very Concerned












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School Aged Referral - May 2015
CONFIDENTIAL
3. Is there a family history of speech, language or communication difficulties? Yes

No

Please explain:
4. Has the child had any of the following:
 Frequent colds

 Recurrent middle ear infections/glue ear

 Asthma

 Developmental Assessment e.g. Griffiths

 Hospitalisation

 A medical diagnosis of: ___________________________
Feeding difficulties
Hearing test
Grommets
Fits/convulsions
Head injury
Please explain providing relevant dates, results and reports where available:
5. Any relevant information that may be impacting on the child’s development
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School Aged Referral - May 2015
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SETTING QUESTIONNAIRE
When completing the questionnaire, please compare the identified child’s
abilities with the performance of children of the same age.
Name of person completing questionnaire:
Date:
Attention and Listening
1. Please describe the child’s attention and listening in a large group, small group and individual setting
2. Please describe the child’s ability to work independently after receiving instructions and during a selfchosen activity
3. Please explain what supporting strategies have been used and whether they have been successful
If you have any concerns around this area please refer to the communication carrousel at
www.oxfordhealth.nhs.uk/slt-bucks for activities and resources to support Attention and Listening.
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School Aged Referral - May 2015
CONFIDENTIAL
Understanding Language
1.
Please describe the child’s ability to understand instructions
2.
Please describe any strategies the child uses to aid his/her understanding
3.
Please explain what supporting strategies have been used and whether they have been successful
If you have any concerns around this area please refer to the communication carrousel at
www.oxfordhealth.nhs.uk/slt-bucks for activities and resources to support Understanding Language.
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School Aged Referral - May 2015
CONFIDENTIAL
Building Sentences and Telling Stories
1.
Please provide 3 examples of sentences spoken by the child (verbatim)
2.
If relevant, please provide 3 sentences written by the child
3.
Please describe the child’s ability to retell a story and/or news
If you have any concerns around this area please refer to the communication carrousel at
www.oxfordhealth.nhs.uk/slt-bucks for activities and resources to support Building Sentences and Telling
Stories.
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School Aged Referral - May 2015
CONFIDENTIAL
Vocabulary
1.
Please describe the child’s understanding and use of vocabulary
2.
If relevant, please give examples of word-finding difficulties:
a.
Using general words instead of the actual words required e.g.
b.
Using a word which sounds similar e.g. “countalator” for “calculator”
c.
Describing what the word means instead of saying it e.g. “bee house” for “hive”
d.
Using a word with a similar meaning e.g. “sticker” for “stamp”
If you have any concerns around this area please refer to the communication carrousel at
www.oxfordhealth.nhs.uk/slt-bucks for activities and resources to support Vocabulary.
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School Aged Referral - May 2015
CONFIDENTIAL
Conversation and Interaction
1. Please describe the child’s ability to work and play with peers
2. Please describe the child’s ability to cope with unexpected changes in routine
3. Please describe the child’s eye contact when listening and speaking
4. Please describe the child’s ability to socialise with his/her peers during his/her unstructured activities
5. Please describe any specific areas of interest which the child particularly likes to discuss
6. Describe any other areas of concern regarding the child’s social communication
If you have any concerns around this area please refer to the communication carrousel at
www.oxfordhealth.nhs.uk/slt-bucks for activities and resources to support Conversation and Interaction.
Speech and Sound Awareness
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School Aged Referral - May 2015
CONFIDENTIAL
1. Please describe how easy/difficult it is for adults and children to understand what the child is saying
2. Please provide some examples (verbatim) of errors which the child makes with his/her pronunciation
If you have any concerns around this area please refer to the communication carrousel at
www.oxfordhealth.nhs.uk/slt-bucks for activities and resources to support Speech and Sound Awareness.
Other Areas of Concern
Please describe any other areas of concern e.g. stammering, voice, and selective mutism in as much detail as
possible
If you have any concerns around these areas please refer to www.oxfordhealth.nhs.uk/slt-bucks for advice
around Stammering and Selective Mutism or www.helpwithtalking.org.uk for advice sheets to support children
who stammer.
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School Aged Referral - May 2015
CONFIDENTIAL
Impact of SLCN
1. Please describe the effects of the child’s speech, language and communication difficulties on his/her
social relationships
2. Please describe the effects of the child’s speech, language and communication difficulties on his/her
self-esteem
3. Please describe the effects of the child’s speech, language and communication difficulties on his/her
behaviour
4. Please describe the effects of the child’s speech, language and communication difficulties on his/her
ability to access the National Curriculum
5. Please provide National Curriculum scores and any other relevant academic information.
Reading:
Writing:
Maths:
Thank you for completing this form. The information you have given will help us to assess your child. In the
meantime use the Communication Carousel on our website to find fun practical ideas and resources to help
support your child’s speech and language needs.
www.oxfordhealth.nhs.uk/slt-bucks
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School Aged Referral - May 2015