Please note all sections are mandatory – Incomplete forms will be returned. Please attach the referral checklist when completing this form. Add additional sheets if necessary If you are referring this child to more than one service (not including audiology) then please refer to the CAF process, do not use this form. Do not use this form for feeding and swallowing referrals. These are made by clinical letter or telephone call only Criteria for Referral: Children and young people aged 2 ½ – 18 years or 19 years if in full time Special Education with speech, language and communication needs. Children aged 0 – 19 years with complex needs. Children and young people registered with a GP within the Bolton area. Referrals are accepted from anyone with the consent of the child’s parents. Single Service Request for Involvement Form for Paediatric Speech and Language Therapy Service Child’s first name : Surname: Gender : M / F Date of birth: NHS No : Address:…………………………………….. ……………………………………………….. ……………………………………………….. GP: Post Code : GP Practice: Home no. …………………………………………….. Mobile no. (Mum, Dad, Guardian) Medical information: Parent’s / Carer’s name: Medication: Does the child have a Safeguarding Looked After Child: YES / NO plan? YES / NO Languages spoken at home Educational setting (include all languages used/dialect School……………………………………. ……………………………………………. Nursery …………………………………. Parents preferred language:………………………………………….... Do parents require an interpreter YES / NO Does the child have a sensorineural hearing loss? YES / NO Please give details ……………………... ……………………………………………. Audiogram attached YES/NO Does the child have a Positive Handling Plan? YES / NO Paediatric Speech and Language Therapy Does the child have a statement YES/NO Educational Psychology Assessment: YES (please attach) / NO / Referred Health Visitor team Assessment: YES (please attach SOGS) / NO CAMHS / Paediatrician Assessment: YES / NO Please attach clinic letter September 2013 Please note all sections are mandatory – Incomplete forms will be returned. Please attach the referral checklist when completing this form. Add additional sheets if necessary Reason for referral ( please give an outline of abilities in each area below) Listening and attention ……………………………………………………………………….. …………………………………………………………………………………………………… Play/social skills ………………………………………………………………………………. …………………………………………………………………………………………………… Understanding ………………………………………………………………………………… ………………………………………………………………………………………………….. Speech sounds and talking …………………………………………………………………. ………………………………………………………………………………………………….. What steps have been taken to address these issues to date? …………………………………………………………………………………………………..... ……………………………………………………………………………………………………. ……………………………………………………………………………………………………. Parental consent to referral: ……………………………………………………………….. Parent aware of reason for referral? ……………………………………………………… Names of other professionals/ services involved? Safeguarding team ……………………………………………………. Educational Psychologist …………………………………………….. Health Visitor / School Nurse ………………………………………... School / Nursery staff ………………………………………………… Consultant …………………………………………………………….. Other …………………………………………………………………... Name of referrer (print)…………………… Signature of referrer………………………. Designation :……………………………….. Location :……………………………………. Phone no. ………………………………….. Date………………………………………… Please send completed form to:Paediatric Speech & Language Therapy Service, Breightmet Health Centre, Breightmet Fold Lane, Bolton, BL2 6NT Tel: 01204 462670 Fax: 01204 463951 Paediatric Speech and Language Therapy September 2013 Please note all sections are mandatory – Incomplete forms will be returned. Please attach the referral checklist when completing this form. Add additional sheets if necessary Paediatric Speech & Language Therapy Referral Checklist This MUST be completed and attached with the referral form, tick all boxes that apply N.B. Referrals will not be accepted for children whose language skills are in line with their cognitive skills unless there is a specific need which should be stated on the referral Under 2 ½ years Child does not understand basic familiar words in context (e.g. ‘it’s bedtime’) Child is passive / non-communicative Child demonstrates unusual communicative behaviours (please give examples in referral form) Child does not understand single words Does not attempt to communicate with familiar adults, even by gesture Child is in ‘a world of their own’ Child has complex needs identified by a Paediatrician 2 ½ years Child uses fewer than 50 words (these do not have to be clear) Does not use two word phrases Has poor interaction skills i.e. poor eye contact Does not understand simple instructions and questions e.g. ‘where’s mummy’s nose?’ 3 years Child not using 2 – 3 word phrases Consistently misses sounds from the beginning or ends of words e.g. ‘ay’ for /say/ and “ha” for /hand/ Parents struggle to understand child’s speech Child does not understand basic instructions or requests e.g. ‘put the spoon on the table’, ‘what are you doing?’ 3 ½ - 4 years Child NOT readily using three – four word phrases Not using many different speech sounds which affects intelligibility Not understanding basic concepts e.g. big / little, on / under Not understanding question words e.g. who, what, where Speech not easily understood except by immediate family Other Child has a significant hearing impairment Child is stammering Child has a tongue tie which affects feeding and swallowing – please send letter Suspected Selective Mutism: consistent failure to speak in specific situations, duration more than 1 month Child has a persistent hoarse voice or voice loss Child has a recently acquired disorder (e.g. acquired brain injury etc…) Medical diagnosis / syndrome associated with communication delay Paediatric Speech and Language Therapy September 2013 Please note all sections are mandatory – Incomplete forms will be returned. Please attach the referral checklist when completing this form. Add additional sheets if necessary REFERRAL FOR THE FOLLOWING SPEECH DIFFICULTIES IS NOT APPROPRIATE PRE-SCHOOL: Difficulties with consonant blends e.g. sp, st, bl, pr, tr etc… Difficulties with sh, ch, j, l, r and th Lisps SPEECH SOUND DEVELOPMENT 4 – 5 years Speech not easily understood except by immediate family Child consistently omits consonants from the starts of words Child consistently omits consonants from the ends of words Child does not use f or s sounds at all Child replaces speech sounds with k and g e.g. gaggy instead of daddy Child uses t and d instead of k or g e.g. tup instead of cup 5 – 6 Years Child has difficulty with consonant blends e.g. sp tr cl etc. Child has difficulty with sh ch j l sounds 7 + Years Child has difficulty with th and r Child has a lisp LANGUAGE DEVELOPMENT 4 – 7+ YEARS Child is not using expected grammatical structures in comparison with other skills (e.g. –ing, the, is etc.) Child is only using short simple sentences with little use of connectors (e.g. because, when, and etc) Child does not appear to understand instructions in the classroom Unusual word order in sentences It is difficult to follow what the child is talking about because of confused content / muddled word order in connected speech/narratives Child had difficulty with semantic skills e.g. limited vocabulary in the absence of any learning / sensory difficulties and /or difficulties with sorting or grouping vocabulary Child has difficulty with pragmatic language skills e.g. using their language appropriately Child had difficulty following conversational rules e.g. turn taking, using appropriate eye contact Child has difficulty with social interaction SECONDARY SCHOOL Referrals will only be accepted for one of the following categories Child has transferred into the area with statement of SEN including Speech and Language Therapy as an educational need in parts 2 & 3 Child requires a speech and language assessment as part of Statutory Assessment Speech sound difficulties / poor intelligibility Child has a recently acquired disorder (e.g. acquired brain injury etc…) Other Child has a significant hearing impairment Child is stammering Child has a tongue tie which affects feeding and swallowing – please send letter Suspected Selective Mutism: consistent failure to speak in specific situations, duration more than 1 month Child has a persistent hoarse voice or voice loss (referral to ENT required prior to SLT) Child has a recently acquired disorder (e.g. acquired brain injury etc…) Medical diagnosis / syndrome associated with communication delay Paediatric Speech and Language Therapy September 2013