SPEECH AND LANGUAGE THERAPY REFERRAL FORM (HALTON)

For information on the service and making referrals please visit:

Name:
NHS number:
D.O.B: / Sex M/F
Ethnic Category:
Address:
Post Code:
Tel No:
Mobile No:
Name of Parent/Legal Guardian:
G.P (name and address):
Language spoken at home:
Interpreter needed: Yes/No
Name of Early Years Setting/School:
am/pm session? (please circle)
Other Professionals involved:
Name and Base
□ Audiology/ENT ______
□ Educational Psychologist ______
□Consultant Paediatrician ______
□ CAMHS ______
□ LA Support Worker ______
□ Health Visitor/School Nurse ______
□ Occupational Therapist ______
□ Physiotherapist ______
□ Other ______
CAF Completed: Yes/No
Looked After Child:Yes/No
Known to Social Services: Yes/No
Social Worker: ______
Base:
Does the parent/carer have any disabilities or support needs:Yes/No
Comments:
Previous referral to SLT: Yes/No
Date:

PLEASE COMPLETE ALL SECTIONS IN FULL OR THE

REFERRAL MAY BE RETURNED

REASON FOR REFERRAL

Please tick which areas the child is experiencing difficulties with: / Please comment how these difficulties are affecting the child:
Attention and Listening skills
Early communication skills (e.g. turn taking, play, eye contact, pointing etc…)
Understanding of spoken language
Ability to use language (e.g. speech, signs, symbols, communication aids etc…)
Speech Sounds
Social Interaction Skills
Stammering
Eating and/or drinking skills
Other Health or Developmental Information (e.g. Diagnoses/Birth History etc)
Is this child’s communication developing at a different rate to their other abilities, e.g. motor skills, learning?
What strategies or techniques have been tried to overcome these difficulties?
What was the result of these?
Are there any factors associated with offering home visits to this family? i.e. parents working hours, safety of staff etc.
If referrer is an early years setting/school, please complete this section
What strategies have you already tried to support this child and how effective were they?
What do you hope to gain from this referral?
School –
Parents –
Child/Young person (if appropriate) –
What SLT Training have staff in your school setting attended?

REFERRER DETAILS AND CONSENT:

Referrer’s Name: ......

Role: ......

Referrer’s Signature: ………………………………………………………………………………………………………

Referrer’s Contact address: ......

Referrer’s Contact telephone number: ...... ……………………………………………

Date: ……………/……………./…………….

Written consentMUST be completed by the Parent /Carer with parental responsibility for the child: Please TICK all boxes that apply

I give consent for my child ……………………………………… to be referred to the Bridgewater Speech and Language Therapy Service.

This is a specialist service for children with complex and disordered communication conditions. If your child’s needs do not meet the criteria for this service, an onward referral can be made to Halton Borough Council Speech and Language Therapy service.

If my child’s needs do not meet the criteria for Bridgewater SLT service, I give consent for his/her details to be shared with Halton Borough Council Speech and Language Therapy Services.

I give consent for the Speech and Language Therapist to liaise with, consult and share information with other people involved with my child

Parent / Carer Name (Print): .………………………………………………………………………………………….

Relationship to child: .…………………………………………………………………………………………………….

Signature: ……………………………………………………………………………………………………………………. Date: .………../……...…./…………

If you would like any help completing this form or if you have any questions please contact:
Bridgewater Speech and Language Therapy Team on: 0151 495 5024
PLEASE RETURN COMPLETED FORM TO:
Bridgewater Paediatric Speech and Language Therapy Service (Halton),
Oaks Place, Caldwell Road, WIDNES WA8 7GD

SLT Referral Form/Halton/CS/JULY 15 1/3