Speech Language Therapy School Age

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School Age - Speech and Language Therapy Referral
Please provide as much information as possible to avoid a delay in processing the referral. Incomplete forms will
be returned to the referrer. For assistance in filling out form, please contact Speech and Language Therapy on
01208 834488
Child Details: (Or attach a copy of patient file)
Name of Child:
Date of Birth:
Address:
NHS Number:
Sex:
Tel Number:
Post Code:
Parents -
Mobile Number:
Mother:
Father:
School:
GP:
Address:
Surgery:
Home language:
Other Languages:
Contact:
Number:
Interpreter Required:
Child’s Ethnicity:
White British
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Mixed White/Black Caribbean
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Asian British Pakistani
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Cornish
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Mixed White & Black African
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Asian British Bangladesh
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White Irish
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Mixed White & Asian
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Any Other Asian
Background
Any Other White Background
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Any Other Mixed Background
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Black British Caribbean
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Black British African
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Any Other Black Background
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Any Other Ethnic Group
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Chinese
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Asian British Indian
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Consent: To be signed by the child’s parent or guardian
I give permission for this referral to be made and for the speech and language therapy service to assess & treat
my child. I also consent to the sharing of information and reports about my child between the speech and
language therapy service and other relevant professionals / services, in order for them to provide the most
appropriate intervention.
Signed:
Name:
Date:
If you DO NOT wish to receive copies of reports about your child please tick:
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Verbal Consent: (Health Professionals)
The referrer has gained verbal consent for:
This referral to be made
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The Speech and Language Therapist to assess & treat the child
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The sharing of information between professionals and services who are part of the Early Help
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Hub response
Chair: Barbara Vann Chief Executive: Phillip Confue
Head Office: Fairview House, Corporation Road, Bodmin, Cornwall,
PL31 1FB
Tel: 01208 251300 Email: [email protected]
Passionate about our services
cornwallfoundationtrust.nhs.uk
Referral Information
Referrer’s Details:
Name:
Designation:
Contact
Address:
Contact Number:
Email Address
Date of Referral
Child’s Current Family & Social Situation:
Who lives at home with the child?
Parents:
Siblings:
Others:
Other significant adults or family members with regular contact?
Please provide any relevant details about the family or child (e.g. culture, traveller community, HM
forces, ethnicity, learning or literacy needs, recent changes in circumstances, accessing short breaks
etc).
Safeguarding:
Child In Need
Has a CAF / TAC / Early
Support been initiated for
this child?
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Child Protection Plan
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Other
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If yes, give lead professional’s details:
Child’s Medical Information:
Details of any medical conditions, diagnoses or developmental delay (e.g. delayed milestones,
learning difficulties, ASD, vision, hearing, asthma, allergies, epilepsy)
Date of last hearing test:
Outcome of last hearing test:
Details of any medication taken by the child:
Does the child experience frequent or recurrent ear, throat or chest infections? (Provide
details about frequency & treatment received).
Chair: Barbara Vann Chief Executive: Phillip Confue
Head Office: Fairview House, Corporation Road, Bodmin, Cornwall,
PL31 1FB
Tel: 01208 251300 Email: [email protected]
Passionate about our services
cornwallfoundationtrust.nhs.uk
Reason for referral
What do you hope to achieve through making this referral to Speech & Language Therapy (see
guidance) that has not been addressed through previous involvement with the SLT service or other
sources of advice & information?
Child’s Education Information:
Teacher/Teaching assistant
Year and class name:
name if appropriate:
ECHP in Place? (Y/N)
Attainment levels : Please describe
For all children of pre-school and school age please provide details of their current Early Years Foundation
Stage, National Curriculum , P levels and EY/S levels – attach copies of recent assessment results or checklists
& IEP if appropriate.
Chair: Barbara Vann Chief Executive: Phillip Confue
Head Office: Fairview House, Corporation Road, Bodmin, Cornwall,
PL31 1FB
Tel: 01208 251300 Email: [email protected]
Passionate about our services
cornwallfoundationtrust.nhs.uk
Speech, Language & Communication Needs
Reason for Referral
Has the child previously been seen by a Speech and Language Therapist?
Date last seen:
Yes
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No
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(If yes please give details of NEW communication issues below)
Please refer to the age-related norms at www.talkingpoint.org.uk and describe the child’s difficulties in
each area, providing as much detail as possible and including relevant examples. State NONE if not a
concern.
Comprehension :
Expressive language:
Difficulties understanding what is said &
following instructions
Difficulties expressing him/her self using
appropriate vocabulary and sentences
Speech clarity:
Social interaction:
Difficulties interacting appropriately with peers and
adults verbally & non-verbally
Difficulties using clear speech appropriate to age
How does the child say these words:
Cat
Man
Fish
Table
Lion
Sauce
Blue
Green
Spider
Chips
Dog
Sun
Fork
House
Fluency of speech / stammering
Difficulty with speaking fluently without excessive
pausing, repetition or stretching out sounds
Other
e.g. Child’s play skills, behaviour, attention &
listening skills.
Eating & drinking / swallowing
Any physical or medical difficulties affecting
eating, drinking or swallowing, e.g. Chewing,
coughing, reflux
Voice
Unusually hoarse / croaky voice / loud / quiet
voice.
Chair: Barbara Vann Chief Executive: Phillip Confue
Head Office: Fairview House, Corporation Road, Bodmin, Cornwall,
PL31 1FB
Tel: 01208 251300 Email: [email protected]
Passionate about our services
cornwallfoundationtrust.nhs.uk
Support already in place
For each area of difficulty please provide details of strategies and support that you have put in place
to help the child already and comment on how successful they have been (this could include parent
groups at the children’s centre, e.g. Toddler Talk, advice from your Health Visitor, educational
psychologist, classroom based strategies, visual support etc.)
Chair: Barbara Vann Chief Executive: Phillip Confue
Head Office: Fairview House, Corporation Road, Bodmin, Cornwall,
PL31 1FB
Tel: 01208 251300 Email: [email protected]
Passionate about our services
cornwallfoundationtrust.nhs.uk
Current Situation:
Parents & referrer to rate where the child is now – please tick
(0 = not at all / never and 10 = extremely / always)
1
How concerned are the child’s parents about his/her speech and language difficulties?
0
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2
3
4
5
6
1
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2
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3
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4
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5
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6
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7
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8
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9
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10
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How concerned is the referrer about the child’s speech and language difficulties?
0
1
2
3
4
5
6
7
8
9
10
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How much are the child’s communication difficulties affecting his/her ability to interact
with / talk to / get along or play with others in everyday situations?
0
1
2
3
4
5
6
7
8
9
10
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How much do you think the child’s speech or language difficulty is affecting their ability to
access the curriculum, including Foundation Stage?
0
1
2
3
4
5
6
7
8
9
10
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How often is the child becoming frustrated, angry or withdrawn due to their
communication difficulty?
0
1
2
3
4
5
6
7
8
9
10
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How aware is the child that he/she has a difficulty with communication?
0
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1
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2
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3
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4
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5
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6
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7
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8
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9
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10
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7
How confident do the parents feel in supporting the child’s communication development?
8
0
1
2
3
4
5
6
7
8
9
10
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How confident does the referrer (if teacher or education worker) feel in supporting the
child’s communication development?
0
1
2
3
4
5
6
7
8
9
10
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Chair: Barbara Vann Chief Executive: Phillip Confue
Head Office: Fairview House, Corporation Road, Bodmin, Cornwall,
PL31 1FB
Tel: 01208 251300 Email: [email protected]
Passionate about our services
cornwallfoundationtrust.nhs.uk
Referrer’s checklist & signature
Have all sections been completed?
Have you included evidence of attainment levels?
Has consent been obtained?
Referrer’s signature:
Send this request to the Early Help Hub [email protected]
Please state the service you are requesting in the subject box of your email. This will
assist in the triaging of your request.
Telephone enquiries: 01872 322277 Monday to Thursday 8.45am to 5.15pm
Friday 8.45am to 4.45pm
Or visit the website www.cornwall.gov.uk/earlyhelphub
Chair: Barbara Vann Chief Executive: Phillip Confue
Head Office: Fairview House, Corporation Road, Bodmin, Cornwall,
PL31 1FB
Tel: 01208 251300 Email: [email protected]
Passionate about our services
cornwallfoundationtrust.nhs.uk
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