Speech and Language Therapy Dept
Oakridge Centre
240 Desborough Road
HIGH WYCOMBE
Buckinghamshire
HP11 2QR
Phone : 01865 901442
Speech and Language Therapy Dept
The Sue Nicholls Centre
Manor House
Bierton Road
Aylesbury
Buckinghamshire HP20 1EG
Phone : 01865 901404
SPEECH AND LANGUAGE THERAPY SETTINGS QUESTIONNAIRE
Name of Child……………………..................Date……………….…………………
Completed by:…..……………………………Role:…….…………………………..
Contact Details:………………………………Child’s School/Pre-school: ………..
To access support from the Speech and Language Therapy Service follow these points:
1.
2.
3.
4.
Complete SLT Referral Form with parental consent
Complete the SLT Settings Questionnaire
Include the last 2 IEPs and copies of relevant reports e.g. E.P.; Cognition and Learning
Send to the address provided on the referral form
The child will then be placed on a waiting list for a Speech and Language Therapy assessment
The questionnaire will cover:
1.
Attention and Listening.
2.
Receptive Language - understanding of language.
3.
Expressive Language- use of spoken language.
4.
Vocabulary and Word Finding
5.
Social Communication
6.
Speech sound production/phonology
7.
Other areas of Concern e.g. stammering
8.
Impact of SLCN
When completing the questionnaire, please compare the identified child’s abilities with the
performance of children of the same age.
Child’s Name :
School/Pre-school:
Attention and Listening
1. Please describe the child’s attention and listening in a large group, small group and individual
setting
2. Please describe the child’s ability to work independently after receiving instructions and during a
self-chosen activity
3. Please explain what supporting strategies have been used and whether they have been
successful
If you have any concerns around this area please refer to www.oxfordhealth.nhs.uk/slt-bucks for
advice sheets to support children with Attention and Listening Difficulties
Child’s Name :
School/Pre-school:
Receptive Language /Understanding
1. Please describe the child’s ability to understand instructions
2. Please describe any strategies the child uses to aid his/her understanding
3. Please explain what supporting strategies have been used and whether they have been
successful
If you have any concerns around this area please refer to www.oxfordhealth.nhs.uk/slt-bucks for
advice sheets to support children with Receptive Language Difficulties.
Child’s Name :
School/Pre-school:
Expressive Language
1. Please provide 3 examples of sentences spoken by the child (verbatim)
2. If relevant, please provide 3 sentences written by the child
3. Please describe the child’s ability to retell a story and/or news
If you have any concerns around this area please refer to www.oxfordhealth.nhs.uk/slt-bucks for
advice sheets to support children with Expressive Language Difficulties.
Child’s Name :
School/Pre-school:
Vocabulary and Word-Finding
1. Please describe the child’s understanding and use of vocabulary
2. If relevant, please give examples of word-finding difficulties:
a.
Using general words instead of the actual words required e.g.
b.
Using a word which sounds similar e.g. “countalator” for “calculator”
c.
Describing what the word means instead of saying it e.g. “bee house” for “hive”
d.
Using a word with a similar meaning e.g. “sticker” for “stamp”
If you have any concerns around this area please refer to www.oxfordhealth.nhs.uk/slt-bucks for
advice sheets to support children with Vocabulary and Word-Finding Difficulties.
Child’s Name :
School/Pre-school:
Social Communication
1. Please describe the child’s ability to work and play with peers
2. Please describe the child’s ability to cope with unexpected changes in routine
3. Please describe the child’s eye contact when listening and speaking
4. Please describe the child’s ability to socialise with his/her peers during his/her during
unstructured activities
5. Please describe any specific areas of interest which the child particularly likes to discuss
6. Describe any other areas of concern regarding the child’s social communication
If you have any concerns around this area please refer to www.oxfordhealth.nhs.uk/slt-bucks for
advice sheets to support children with Social Communication Difficulties
Child’s Name :
School/Pre-school:
Speech Sound Production/Phonology
1. Please describe how easy/difficult it is for adults and children to understand what the child is
saying
2. Please provide some examples (verbatim) of errors which the child makes with his/her
pronunciation
If you have any concerns around this area please refer to www.oxfordhealth.nhs.uk/slt-bucks for
advice sheets to support children with Phonological Difficulties.
Child’s Name :
School/Pre-school:
Other Areas of Concern
Please describe any other areas of concern e.g. stammering, voice, and selective mutism in as much
detail as possible
If you have any concerns around these area please refer to www.oxfordhealth.nhs.uk/slt-bucks for
advice sheets around Stammering and Selective Mutism or www.helpwithtalking.org.uk for advice
sheets to support children who stammer.
Child’s Name :
School/Pre-school:
Impact of SLCN
1. Please describe the effects of the child’s speech, language and communication difficulties
on his/her social relationships
2. Please describe the effects of the child’s speech, language and communication difficulties
on his/her self-esteem
3. Please describe the effects of the child’s speech, language and communication difficulties
on his/her behaviour
4. Please describe the effects of the child’s speech, language and communication difficulties
on his/her ability to access the National Curriculum
5. Please provide Bucks Developmental Curriculum Record or National Curriculum scores
Please also refer to the www.talkingpoint.org.uk website for additional advice