PLEASE USE BLACK INK
SCHOOL AGE REFERRAL FORM: SPEECH AND LANGUAGE THERAPY
GENERAL INFORMATION
NHS NO:
Please indicate reason for referral: (Please tick appropriate box(es)
Communication
Feeding
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Surname.................................................................. DOB.............................................
First name.............................................................. Male/Female..................................
Parent’s surname (if different from child).......................................................................
Address............................................................................................................................
..................................................................... Postcode...............................................
Home telephone................................. Mobile (parent/carer’s)......................................
Would you be happy for us to contact you (parents/carers) by email? .........................................
Parents/Carers Email Address ...........................................................................................
School.................................................. Contact person in school.................................
GP..................................................................................................................................
ADDITIONAL INFORMATION:
Home language........................................ Interpreter required for parents…YES/NO
Other agencies involved (if any)....................................................................................
Any hearing concerns? (If yes, please specify).............................................................
EDUCATIONAL INFORMATION:
Code of practice stage (please tick):
Not on code of practice  School action  School action plus  Statement 
Please tell us what support is available in school for the child:
Support in the classroom:
1:1 support to deliver speech and language programme of work:
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Please give us some information about the child’s communication difficulty and
explain how it is affecting them academically and socially
What strategies are currently being used in school to support the child’s
communication?
Please tell us what are the child’s current National Curriculum Levels:
English...........................................................................................................................
Numeracy......................................................................................................................
Science..........................................................................................................................
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REFERRAL
Reason for referral:
What specifically would you hope to happen as a result of the speech and language
therapy assessment?
Has the child been referred to speech and language therapy before?
YES/NO.................................................................................
If yes, please give details:
Referred by:
Name............................................................ Designation.............................................
Address............................................................................................................................
.................................................................. Date........................................................
Postcode……………………………………… Telephone no:.........................................
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CONSENT
*Please note, parental signatures are required.*
I give consent for my child to be referred to speech and language therapy
...........................................................................(Parent/Guardian please sign)
I give consent for information related to my child’s therapy to be shared/ discussed
with health/education/other colleagues including the sharing of electronic records with
GP
........................................................................... (Parent/Guardian please sign)
I give consent for information to be shared about the dates and times of my child’s
appointments
........................................................................... (Parent/Guardian please sign)
Ethnicity
White
Black or Black British
01  British
02  Irish
03  An other white background
group
12  Caribbean
13  African
14  Any other Black background within this
Mixed
Other ethnic group
04  White & Black Caribbean
05  White & Black African
06  White & Asian
07  Any other mixed background
Asian or Asian British
15  Chinese
16  Any other ethnic group
Please note: the above ethnic origin
classification is based on advice by the
Commission for Racial Equality.
08  Indian
09  Pakistani
10  Bangladeshi
11  Any other Asian background within this group
Please note, this form may be returned if not all relevant sections have been
completed.
Please return this form to, Speech and Language Therapy Service, Locala
Community Partnerships, Batley Health Centre, 130 Upper Commercial Street,
Batley WF17 5ED. Tel 01924 351546
For office use only:
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Date referral received ………………………………….
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CHILDREN’S SPEECH AND LANGUAGE THERAPY SERVICE
DISCHARGE POLICY
When will my child’s name be removed from the Speech and Language Therapy list?
At any one time, there are approximately 400 children on the Speech and Language
Therapy list some of whom are getting therapy and some of whom are waiting. Each
week some children are added to our list and some children are removed from our list.
This advice sheet has been written to help you understand when we would remove your
child’s name from our list.
Reason 1:
Your child doesn’t need speech and language therapy.
This will happen when your speech and language therapist decides
that your child’s speech, language and communication skills are within
normal limits.
Reason 2:
Your child doesn’t need speech and language therapy NOW. Your
speech and language therapist will give you some advice about when
your child might need to be seen again.
Reason 3:
You can’t keep or you miss your appointment and you forget to tell us
- if this happens you need to let us know straight away. REMEMBER
if we don’t hear from you, your child’s name will be removed from our
list.
The telephone number for appointments is: 01924 351577
PLEASE NOTE:
If your child has been discharged three times for failing to
attend, a fourth referral may not be automatically accepted.
- - Sometimes the Speech & Language Therapist may see your child without you being
in the room. However, please do not leave the waiting area in case you are needed
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