ADULT SPEECH & LANGUAGE THERAPY SERVICE - COMMUNITY REFERRAL FORM
Thank you for referring to the Community Adult Speech and Language Therapy Service (18 years+).
Please complete the following pages with as much information as possible
ALL RELEVANT SECTIONS MUST BE COMPLETED (incomplete referrals will be returned)
Please note that currently we do not accept referrals for communication or swallowing difficulties that
result from the following conditions in isolation: Developmental disorders that continue into adulthood
(including dysfluency/stammering), Mental Health disorders, Chronic cough, and Facial Palsy
PERSON BEING REFERRED
Name of person:
NHS number:
Stated ethnicity:
Address:
Date of birth:
Presently situated at:
Home
St. Peter’s ward
Braintree ward
OTHER (Give details):
_________________________________________________________________________________
REFERRER DETAILS
Name:
Job title:
Self (please tick):
Full contact address and phone number:
_________________________________________________________________________________
MEDICAL BACKGROUND
Relevant diagnosis and past medical history:
Relevant medication:
SWALLOWING REFERRALS ONLY:
Has the individual had a chest infection in the last 6 months?
Yes
No
Has the individual been seen by this service before?
Yes
No
If yes, are there concerns that the existing guidelines are
no longer appropriate?
Yes
No
Current diet and fluid consistencies (please state):
Reason for referral to service at this time (Please mark as appropriate):
New episodes of coughing / choking with fluids
Re-current chest infections / aspiration
New episodes of coughing / choking with food
Reduced ability to manage secretions
Exacerbation of pre-existing swallow difficulties
Food/residues sticking in throat
Other (please detail):
How long have the symptoms been occurring?
Have there been any related investigations (e.g. Ba swallow / OGD)?
2
VIDEOFLUOROSCOPY
Videofluoroscopy may be considered to help inform the management of swallowing disorders. Please
note that SLT’s are now non-medical referrers for this procedure and GP referral is no longer
essential. Please indicate below if you know of any contraindications to this procedure for the
individual being referred. (E.g. Recent significant heart operation or extensive exposure to previous
radiological investigations).
No contraindications known
Contraindications to be considered
(please detail):
*If you are not a GP / medical referrer, please check with the individual’s GP about any known
contraindications to videofluoroscopy BEFORE submitting this referral form
VOICE REFERRALS ONLY:
Has the patient had an ENT examination within the last 6 months?
Yes
Report must be attached to referral
No
Referral must be made to ENT initially
COMMUNICATION REFERRALS ONLY:
SPEECH
LANGUAGE
Very quiet
Difficulties finding words
Imprecise / slurred
Uses wrong words /wrong sounds in words
Very slow/very fast
Appears to use nonsense words or sentences
Difficulty reading
Other (describe):
Difficulties with writing
Difficulty understanding spoken language
Other (describe):
SOCIABILITY AND PREVIOUS COMMUNICATION FUNCTIONING
Not talkative – very limited
social involvement
Very talkative – highly sociable –
Enthusiastic communicator
____________________________________________________________________________
0
Please indicate your rating with a mark on the scale
10
LEVEL OF CONCERN
No concern – only mild impact
upon functioning and well-being
Serious concern – huge impact
upon functioning and well being
____________________________________________________________________________
0
Please indicate your rating with a mark on the scale
10
Please return this form to: Adult Speech and Language Therapy Department,
St. Peter’s Hospital, Spital Road, Maldon, Essex, CM9 6EG. Fax to: 01621 727243
OR submit the referral via Systmone