Forms must be completed in one go. You will NOT be able to save the part-completed form and return to it later.
Please use the list of question below as an aid to gather all the necessary information required for the referral. Please note missing information is more likely to delay the process as the referral will not be accepted by the system.
- Your email address
- Referred by (referring person name)
- Designation or Relationship to Child
- Your Contact Number
- The surname of Child/Young Person (Person being referred)
- First Name (Person being referred)
- Date of Birth (Person being referred)
- NHS Number (optional)
- Child/Young Person has a EHCP in place
- Details of Parent/Carer name (primary)
- Parent/Carer address (primary)
- Parent/Carer contact number (primary)
- Parent/Carer email address (primary)
- Details of Parent/Carer name (secondary)
- Parent/Carer address (secondary)
- Parent/Carer contact number (secondary)
- Parent/Carer email address (secondary)
- Emergency Contact Name
- Relationship to the child (Emergency Contact)
- Emergency Contact Daytime Contact Number/ Mobile
- Home Language
- Is an Interpreter required
- Will carers have any difficulties reading appointment letters
- Name of School/Nursery/Playgroup/Setting
- If the child attends pre-school can you please select the time slot they attend
- Telephone number
- GP Name and Practice Address
- The child has a Child Protection Plan
- Is the child a Child in Need (CiN)
- Is the child in the care of the Local Authority (If Yes, Details will be required)
- Is the child in the care of the Local Authority
- Has the person with legal responsibility consented to this referral and sharing of information
- Area of concern: Attention and Listening
(e.g. poor concentration, highly distractable, not able to focus on adult led activities for an age-appropriate length of time)
- Area of concern: Understanding of Language
(e.g. not able to follow instructions, answer questions, or understand concepts at an age-appropriate level)
- Area of concern: Expressive Language (talking)
(e.g. limited vocabulary development, difficulties using age-appropriate spoken grammar/sentence structure, word finding difficulties)
- Area of concern: Speech/Articulation
(e.g. unclear speech, incorrect or limited speech sounds used)
- Area of concern: Social Skills
(e.g. difficulties with turn taking, keeping to topic, literal interpretation of language, limited awareness of other children/adults, difficulties with friendships)
- Area of concern: Play
(e.g. not engaging in pretend/imaginative play at an age-appropriate level, shows only repetitive/copied play, limited interests, not able to join in with shared play activities)
- Area of concern: Oro-motor/ Feeding
(e.g. difficulties with chewing/swallowing/choking (not due to behavior), difficulties with general muscle control of lips/mouth/tongue)
- Area of concern: Voice
(e.g. persistent hoarse/weak voice quality, vocal nodules, excessively nasal voice quality)
- Area of concern: Dysfluency
(e.g. Stammering/Stuttering, not being able to ‘get words out’ with ease)
- Any other concerns with descriptions
- What academic levels is the child currently working at?
- Please describe and/or give examples of what the child’s speech, language and/or communication difficulties look like
- What strategies and support are already in place for the client (intervention, targets, homework, etc.)? What difference has this made?
- Why would you like this client to receive speech and language therapy? Ideally, what would you like him/her to achieve?
- Activity: How able is the child to communicate effectively?
- Well-Being: how does the child feel as a result of his/her speech, language and/or communication difficulties?
- Have parents been notified of this referral?
- Please ensure you have parental consent before making this referral.
- Has the school SENCO been informed of this referral? (Please note if you are a teaching staff making this referral you must notify the SENCO of this referral)
- Comments/Additional Information