Information Governance
This form must not be forwarded to Speech
& Language by email as it contains
Confidential/Sensitive Information.
Speech & Language Service
Undercliffe Health Care Centre
17 Lowther St
Bradford BD2 4RA
Tel: 01274 770397
Fax: 01274 783188
To be posted / faxed only.
SPEECH AND LANGUAGE THERAPY REFERRAL FORM - GENERAL INFORMATION
PLEASE PRINT ALL DETAILS
SURNAME____________________________________ FORENAME(S)___________________________________
DATE OF BIRTH_______________________________ SEX M
/ F (PLEASE DELETE)
ADDRESS ____________________________________________________________________________________
________________________________________________ POSTCODE ____________________________
TELEPHONE NUMBER _____________________________ GP _________________________________________
MOBILE NUMBER __________________________________ CONSENT TO RECEIVING TEXT MESSAGES
Y/N
HOME LANGUAGE _________________________________ INTERPRETER REQUIRED Y / N (PLEASE DELETE)
IF YES, PLEASE STATE LANGUAGE_______________________________________________________________
SCHOOL/ NURSERY ATTENDED (IF APPROPRIATE) ________________________________________________
OTHER HEALTH/EDUCATION INVOLVED __________________________________________________________
HAS THE CLIENT BEEN REFERRED TO SLT BEFORE Y / N (PLEASE DELETE)
IF YES – OUTCOME ____________________________________________________________________________
HAS ANY OTHER FAMILY MEMBER HAD SLT PROBLEMS Y / N (PLEASE DELETE)
ANY OTHER RELEVANT INFORMATION____________________________________________________________
_____________________________________________________________________________________________
CONSENT (PLEASE TICK) – Please note that if this section is not ticked and signed the form will be returned
[
] REFERRAL, ASSESSMENT AND TREATMENT IF APPROPRIATE
[
] DISCUSSION AND SHARING OF INFORMATION WITH HEALTH/EDUCATION PARTNERS
SIGNATURE OF PARENT / CARER ________________________________________________________________
REFERRED BY
NAME ________________________________________ DESIGNATION __________________________________
ADDRESS FOR REPORT _______________________________________________________________________
TELEPHONE NUMBER _________________________________________________________________________
SIGNATURE _______________________________________________ DATE ____________________________
Bradford District Care Trust
Speech and Language Therapy Services
EDUCATION
REFERRAL INFORMATION:
OUTLINE OF MAIN CONCERNS:
SPEECH SOUNDS
LANGUAGE
COMMUNICATION (SOCIAL INTERACTION)
STAMMER
BRIEF DESCRIPTION:
WHAT WOULD YOU LIKE TO HAPPEN AS A RESULT OF THIS REFERRAL?
IF THIS CHILD HAS BEEN REFERRED BEFORE, WHY IS THIS RE-REFERRAL
NECESSARY?
WHAT STRATEGIES HAVE BEEN USED (AT HOME / SCHOOL) TO HELP?
EDUCATIONAL INFORMATION:
IMPACT OF DIFFICULTY WITHIN THE SCHOOL SETTING / CODE OF PRACTICE
STAGE:
EARLY YEARS ACTION
EARLY YEARS ACTION PLUS
SCHOOL ACTION
SCHOOL ACTION PLUS
STATEMENT WITH SLT
STATEMENT WITH NO SLT
DOES THE CHILD HAVE SUPPPORT IN SCHOOL?
YES / NO
WHICH SCHOOL BASED STAFF WILL BE RESPONSIBLE FOR INTEGRATING
SLT TARGETS INTO IEP’s?
CONCERN:
CHILD CONCERN?
- LOW / MEDIUM / HIGH
PARENTAL CONCERN?
- LOW / MEDIUM / HIGH
SCHOOL CONCERN?
- LOW / MEDIUM / HIGH
IMPACT OF DIFFICULTY?
- LOW / MEDIUM / HIGH
TICK BOX IF YOU WOULD LIKE NOTIFICATION OF INITIAL APPOINTMENT FOR
CHILD.