Speech & Language Therapy Service
Unit 3 – Horton Park Medical Centre
99 Horton Park Avenue
Bradford BD7 3EG
Tel: 01274 770397
Fax: 01274 323960
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.