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