SUFFOLK

Parental permission MUST be obtained prior to the referral being made.

SPEECH & LANGUAGE THERAPY PAEDIATRIC REFERRAL
Note: all incomplete referrals will be returned to referrer.
PLEASE COMPLETE FULLY AND LEGIBLY IN BLACK INK.

D.O.B. / / Ethnicity:
M □ F □ Religion:
Telephone No(s):
G.P. Name: Practice:
School/Nursery/Preschool:
Health Visitor/School nurse: / Parent/Carer Name(s):
Relationship to Child:
Address:
Postcode:
Telephone No(s):
Names of those with Parental responsibility:
Other Members of the Household:
Main Language spoken at home:
Referrer Information
Name (please print): Signature: Date: / /
Job Title: Address: Tel. No:
Name of Staff Member to make appointment with:
If this referral is for Speech and Language Therapy assessment of eating and drinking skills please give details of difficulties/concerns in the box below:
NB: Referrals for eating and drinking assessment must be signed by a medical doctor, eg. GP, Consultant etc.
Reason for Referral [e.g. comprehension difficulties, unclear speech, stammer, reluctant to speak, social communication difficulties, language difficulties etc]. Please describe the child’s communication difficulties in the box below:
NB: We can only accept referrals for voice difficulties once ENT have assessed vocal cord function.
Name: NHS Number:
Please add comments about other aspects: eg. child’s attention, social interaction, general level of ability, coordination, reading and writing skills etc (include information about areas of strength as well as difficulty):
Any Child Protection Issues?
Y N / Is this child a Looked After Child?
Y N / Has a CAF been completed?
Y N
Other Observations:
Does the child have any vision or hearing difficulties?
Date of last hearing test:
Are there any relevant diagnoses or medical problems?
Names of other key professionals involved: (Eg. Paediatrician, Portage Worker, Educational Psychologist)
Any other concerns:
Has the Child previously been referred to Speech & Language Therapy?
Details:
Note: Home visits are often made by a lone worker. Are there any issues / concerns about lone workers and this family? Yes No
Details:
Date parental consent gained for referral: / /
Name of person giving consent:
Parental Consent for sharing
Do you consent to the information that is recorded about your child here being made available to otherNHS care services that care for your child and also use Systm1?
Yes No
Do you consent to allow this care service to view information about your child that has been recorded at other services where your child also receives care? (You must also have consented forinformation to be 'shared out' of those services)
Yes No
Please return completed referral form to:
Speech & Language Department, Kirkley Mill Health Centre, Clifton Road, Kirkley, Lowestoft,Suffolk, NR33 0HH
Telephone: 01502 448676

Note: All incomplete referrals will be returned to the referrer

Please attach any recent and relevant reports

30.04.14

Working with other NHS services involved in your care:

Sharing your medical record

The electronic record system that East Coast Community Healthcare uses, allows us to share your medical records with those in the NHS who are involved in your care. At your first clinical contact you will be asked for permission for us to continue doing this. You can retract this permission at any time and we will stop sharing your record.

We ONLY share the record with other NHS services that you have agreed can view it.

For example:

  • If you give your GP consent to share your information and view the shared information.
  • You then give the District Nurse consent to share your information and view the shared information.
  • You give the Smoking Clinic consent to share your information, however NOT to view the shared information

This would mean that:

  • Your GP is able to view the information shared by the District Nurse and the Smoking Clinic.
  • The District Nurse is able to view the information shared by your GP and the Smoking Clinic.
  • However the Smoking Clinic is only able to share and view their own information, they cannot see anything that the GP or District Nurse have shared.

We will NEVER share with insurance companies, banks, the DVLA, without your written consent or, in very exceptional circumstances, a court order.