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 the Care Management Centre on
01208 834488
Child Details: (Or attach a copy of patient file)
Name of Child:
Address:
Date of Birth: Sex:
CR Number:
NHS Number:
Post Code:
Parents -
School:
Address:
Mother:
ICS Number:
Tel Number:
Mobile Number:
Father:
GP:
Surgery:
Home language:
Other Languages:
Contact:
Number:
Child’s Ethnicity:
White British
Cornish
White Irish
Any Other White Background
Black British African
Interpreter Required:
Mixed White/Black Caribbean
Mixed White & Black African
Mixed White & Asian
Any Other Mixed Background
Any Other Black Background
Asian British Pakistani
Asian British Bangladesh
Any Other Asian
Background
Black British Caribbean
Any Other Ethnic Group
Chinese Asian British Indian
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:
Verbal Consent: (Health Professionals)
The referrer has gained verbal consent for:
This referral to be made
The Speech and Language Therapist to assess & treat the child
The sharing of information between professionals and services
Chair: Vicky Wood Chief Executive: Phillip Confue
Head Office: Fairview House, Corporation Road, Bodmin, Cornwall,
PL31 1FB
Tel: 01208 251300 Email: CFTenquiries@Cornwall.NHS.UK
Passionate about our services cornwallfoundationtrust.nhs.uk

Referrer’s Details:
Name:
Contact
Address:
Designation:
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:
Has a CAF / TAC / Early this child?
Child In Need Child Protection Plan
If yes, give lead professional’s details:
Support been completed for
Other
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).
Child’s Education Information:
Teacher/Key worker name: Year and class name: SEN assessment stage:
Attainment levels
For all children of pre-school and school age please provide details of their current Early Years Foundation
Stage, National Curriculum or P levels
– attach copies of recent assessment results or checklists & IEP if appropriate.
Chair: Vicky Wood Chief Executive: Phillip Confue
Head Office: Fairview House, Corporation Road, Bodmin, Cornwall,
PL31 1FB
Tel: 01208 251300 Email: CFTenquiries@Cornwall.NHS.UK
Passionate about our services cornwallfoundationtrust.nhs.uk

Please provide details of other professionals involved with the child
Agency (Insert Name) Contact No. if known Frequency of contact
Health Visitor
School Nurse
Consultant / paediatrician
Other Medical Doctor
Social Worker
Educational Psychologist
CAMHS
Family Support Worker
ASD Team
Behaviour Support Service
Early Years Inclusion Service
Occupational Therapist
Physiotherapist
Sensory Support Service
(Teach of the Deaf / Vision Support)
Short Breaks provider
Other
Chair: Vicky Wood Chief Executive: Phillip Confue
Head Office: Fairview House, Corporation Road, Bodmin, Cornwall,
PL31 1FB
Tel: 01208 251300 Email: CFTenquiries@Cornwall.NHS.UK
Passionate about our services cornwallfoundationtrust.nhs.uk

Reason for Referral – Early Years (0 – 4) :
Please complete the relevant section for children aged 0 – 48 months (4 years)
Age of child Reason for Referral (Tick) Please add further details
All Age ranges
Child has eating and drinking / swallowing difficulties
0 – 24 months
Referral ONLY by Paediatrician,
Portage or Senior Locality SENCo
– with copy of recent report
25 – 30 months
Child is using less than 10 spoken words
Child has been stuttering / stammering for 2 months or more
31 – 40 months
Has unusual or obsessive interest in certain types of play (e.g. excessive spinning of toys) AND uses limited eye contact & pointing
Child cannot follow a short verbal instruction
Child is only using single words or two-word sentences
Child has been stuttering / stammering for 2 months or more
Has unusual or obsessive interest in certain types of play (e.g. excessive spinning of toys)
41 – 48 months
Has poor social skills (e.g. difficulty initiating & playing with other children AND uses limited eye contact & pointing
Child is not regularly using 4 – 5 word sentences
Others cannot understand what the child is saying (unclear speech)
How does the child say these words:
Cat
Fish
Lion
Blue
Spider
Man
Table
Sauce
Green
Chips
Child is stuttering / stammering
Poor social skills, including:
-limited imaginative play
-repetitive behaviours
-poor eye contact
-difficulty turn-taking
-obsessive about certain topics
-difficulty maintaining conversation
Chair: Vicky Wood Chief Executive: Phillip Confue
Head Office: Fairview House, Corporation Road, Bodmin, Cornwall,
PL31 1FB
Tel: 01208 251300 Email: CFTenquiries@Cornwall.NHS.UK
Passionate about our services cornwallfoundationtrust.nhs.uk

Reason for Referral - School Age (4 – 19)
Has the child previously been seen by a Speech and Language Therapist? Yes No
Date last seen: (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 :
Difficulties understanding what is said & following instructions
Expressive language:
Difficulties expressing him/her self using appropriate vocabulary and sentences
Speech clarity:
Difficulties using clear speech appropriate to age
How does the child say these words:
Cat Man
Fish
Lion
Blue
Spider
Table
Sauce
Green
Chips
Social interaction:
Difficulties interacting appropriately with peers and adults verbally & non-verbally
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: Vicky Wood Chief Executive: Phillip Confue
Head Office: Fairview House, Corporation Road, Bodmin, Cornwall,
PL31 1FB
Tel: 01208 251300 Email: CFTenquiries@Cornwall.NHS.UK
Passionate about our services cornwallfoundationtrust.nhs.uk

Early years/ school age- support already in place
For each area of difficulty please provide details of strategies and support that have been put in place to help the child already and comment on how successful they have been.
Chair: Vicky Wood Chief Executive: Phillip Confue
Head Office: Fairview House, Corporation Road, Bodmin, Cornwall,
PL31 1FB
Tel: 01208 251300 Email: CFTenquiries@Cornwall.NHS.UK
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 1 2 3 4 5 6 7 8 9 10
2 How concerned is the referrer about the child’s speech and language difficulties?
3
4
5
0 1 2 3 4 5 6 7 8 9 10
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
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
How often is the child becoming frustrated, angry or withdrawn due to their communication difficulty?
9 10
0 1 2 3 4 5 6 7 8 9 10
6 How aware is the child that he/she has a difficulty with communication?
0 1 2 3 4 5 6 7 8 9 10
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
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
What do you hope to achieve through making this referral to Speech & Language Therapy (see guidance) that has not been addressed through previous involvement or other sources of advice & information?
Chair: Vicky Wood Chief Executive: Phillip Confue
Head Office: Fairview House, Corporation Road, Bodmin, Cornwall,
PL31 1FB
Tel: 01208 251300 Email: CFTenquiries@Cornwall.NHS.UK
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:
Please print and return the completed form to:
By post:
Children’s Services Care Management Centre
Truro Health Park
Infirmary Hill
Truro
TR1 2JA
By telephone to:
01872 221400
OFFICE USE ONLY
Form complete:
Date registered:
Triager’s Name:
First appt date:
Date received:
Date returned:
Team:
Accepted:
KITS No:
Date Ack’d:
Date received back:
Date Triaged:
Caseload:
NHS No:
Chair: Vicky Wood Chief Executive: Phillip Confue
Head Office: Fairview House, Corporation Road, Bodmin, Cornwall,
PL31 1FB
Tel: 01208 251300 Email: CFTenquiries@Cornwall.NHS.UK
Passionate about our services cornwallfoundationtrust.nhs.uk