Halton Referral Form Questions
When completing our Halton Referral Form, please ensure you have all the required information as this would need to be completed in full.
To help you gather the required information, please see the following list of questions.
- Referrer’s Email Address
- Name of Referrer
- Designation or Relationship to Child
– Case Worker / Child Minder / Community Nursery Nurse / Education Service / GP / Health Visitor / OT / Paediatricians / Parent/Carer / Physiotherapy / School Nurses / School/Setting / SLT / Other
- Contact Number
- Case Worker Name
– If not applicable enter N/A
- Child’s Surname
- Child’s First name
- Child’s Date of Birth
- Child’s Sex
- Does the child/young person have an EHCP in place?
- Who has parental responsibility?
– Main parent/carer
– Second parent/carer
- Main Parent/Carer Name
- Main parent/carer relationship to the child
- Main parent/carer address
- Main parent/carer post code
- Main parent/carer contact number
- Main parent/carer email address
- Second parent/carer Name
- Second parent/carer relationship to the child
- Second parent/carer address
- Second parent/carer post code
- Second parent/carer contact number
- Second parent/carer email address
- Emergency contact name
- Emergency contact relationship to child
- Emergency contact contact
– British / Scottish / Irish / Welsh / Indian, Indian Scottish or Indian British / Pakistani, Pakistani Scottish or Pakistani British / Bangladeshi, Bangladeshi Scottish or Bangladeshi British / Chinese, Chinese Scottish or Chinese British / African, African Scottish or African British / Caribbean, Caribbean Scottish or Caribbean British / Black, Black Scottish or Black British / Arab, Arab Scottish or Arab British / Other
- Any other ethnic group, please describe
- Home language
- Interpreter required
- Will carers have any difficulties reading appointment letters
- Details of School/Nursery/Playgroup
- Name of School/Nursery/Playgroup/Setting
- If the child attends pre-school can you please select the time slot they attend:
- Setting contact number
- Details of GP – Name and Practice Address
- Child Protection Details (if any)
- Child protection plan in place
- Is the child a Child in Need (CiN)
- Is the child in the care of the Local Authority?
- Is there a CAF in place?
- Consent/Information Sharing
- Has the person with legal responsibility consented to this referral and sharing of information?
- What is your main area of concern? (Score 0 for no concerns at all and 5 for severe difficulties in this area)
- Attention and Listening
e.g. poor concentration, highly distractable, not able to focus on adult led activities for an age appropriate length of time
- Understanding of Language
e.g. not able to follow instructions, answer questions, or understand concepts at an age appropriate level
- Expressive Language (talking)
e.g. limited vocabulary development, difficulties using age appropriate spoken grammar/sentence structure, word finding difficulties
e.g. unclear speech, incorrect or limited speech sounds used
- Social Skills
e.g. difficulties with turn taking, keeping to topic, literal interpretation of language, limited awareness of other children/adults, difficulties with friendships
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
e.g. difficulties with chewing/swallowing/choking (not due to behavior), difficulties with general muscle control of lips/mouth/tongue
e.g. persistent hoarse/weak voice quality, vocal nodules, excessively nasal voice quality
e.g. Stammering/Stuttering, not being able to ‘get words out’ with ease
- Do you have any other areas of concern?
- Describe why these are areas of concern
- Additional Information
- Does the child have a current diagnosis of any of the following
– ADHD / Autism / Cerebral Palsy / Cleft Lip and Palate / Dysphagia / Hearing Impairment / Learning Disability / Selective Mutism / Selective Mutism (linked to anxiety) / SEMH Needs (Social and Health Need) / No Diagnosis
- 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? (e.g. ‘to be able to read his lines in the school play clearly’; ‘to make and maintain a friend’; ‘to independently make requests to get everyday needs met’; ‘to answer questions in class’; ‘to follow instructions in lessons’, etc.)*
- Activity: How able is the child to communicate effectively? (0 = unable to communicate/be understood in any way; 5 = communicates/is understood well in all situations)
- Well-Being: how does the child feel as a result of his/her speech, language and/or communication difficulties?(0=constantly very distressed/frustrated; 5=no distress/frustration)
- Have parents been notified of 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
- Date Referral form completed