Adult Speech and Language Therapy in the Community Referral Form

Adult Speech and Language Therapy In The Community Referral Form

A service for adults with acquired neurological disorders of communication or swallowing

This Person Needs Support with their Appointment

Please indicate any communication support you use when interacting with this person:

Spoken Language Interpreter British Sign Language Interpreter

Communicator Guide for people with dual sensory loss

Other eg. Learning Disability

(Please state language and dialect or other support needed in the space below)

Date Of Referral:
Name / Date of Birth
Age / Gender / NHS Number
Address / Telephone / Home:
Mobile:
Next of kin / Next of kin telephone number
Name and title of Referrer / Referrer address and telephone number
GP Name: / Surgery Address:
Surgery Code:
Surgery Phone:
Fax:
Ethnicity / Interpreter Required? / Y/N / If Y specify language:
Special Requirements?
If yes please state:
(e.g. Hearing Loop, Wheelchair Access)
REASON FOR REFERRAL (Please tick as appropriate)
Swallowing □
What are the current diet and fluid recommendations? Please tick:
Normal diet □ Normal fluids □
Easy chew □ Pre-Stage 1 □
Fork mashable □ Stage 1 □
Pre mashed □ Stage 2 □
Pureed □
Other (please state recommendations below):
What are the swallowing symptoms? Please tick:
Coughing/ choking on food □ Coughing/ choking on fluids □
Pocketing food □ Leaving food/ poor intake □
Recurrent chest infection □ Absent swallow □
Other (please state problem below):
What is the frequency of the problem? Please tick:
Almost every time they have a meal/drink □ 4-5 times a day □
1-2 times per day □ Occasional/ one off (choking) □
Please ensure resident has been observed and the difficulties recorded above are accurate and all carers are in agreement □
Any other relevant information:
Communication □
If communication describe the problem:
MEDICAL HISTORY (please include any relevant diagnosis)
OTHER PROFESSIONALS INVOLVED IN CARE (Please give names, titles and contact details)
DETAILS OF ANY PREVIOUS SPEECH AND LANGUAGE THERAPY INVOLVEMENT
(name of Therapist and date of involvement)
IS THE PATIENT AWARE OF THE REFERRAL? / Yes/No
ARE THERE ANY PROBLEMS WITH (please tick as appropriate):
Vision □ Hearing □ Memory □ Attention/Concentration □
PLEASE RETURN TO:
COMMUNITY SPEECH AND LANGUAGE THERAPY
DENTON PARK HEALTH CENTRE, WEST DENTON WAY, NEWCASTLE UPON TYNE, NE5 2QE
FAX: 0191 2678825 TEL: 0191 2138841
E-MAIL:
(E-MAIL FOR REFERRALS ONLY)