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AchievingBetterCommunication Groups

CONFIDENTIAL REFERRAL INFORMATION

Edinburgh / Glasgow / Aberdeen / Orkney / Perth / Angus

ABC Area:

Please state preference______

Name of child: / Date of birth:
Parents name(s):
Address:
Postcode:
Telephone:
Mobile:
Email:
G.P. Name: / SLT Name:
Address: / Address:

Please list names and contacts of other professionals involved with your child:

Name. / Profession. / Contact No. / How often seen.

Medical Information:

Hearing:
When was hearing last checked?
Vision:
When was vision last checked?
Other medical information:
Does your child sleep well? Please give details e.g. hours per night, early riser, sleep problems such as disturbances, bed wetting etc…
Does your child eat well? Please give details e.g. bottle/breastfed, type of textures, self-feeding, chewing, any choking episodes etc…

What is your child good at? What does s/he enjoy?

Play skills: Who does your child like to play with and what sorts of games does s/he play?

Any other information that you think would be relevant when talking with your child?

Language skills:How does your child communicate? Does this vary in different settings or with different people? Does your child use single words, phrases or sentences? Please give examples of “best” signed/ spoken language used.

Vocabulary skills: Please give examples of the words/ signs that your child uses, including names of things (nouns) e.g. “computer”, action words (verbs) e.g. “jump”, describing words (adjectives) e.g. “enormous”, time words e.g. “later”, “tomorrow”, and linking words e.g. “the”, “on”, “at”, “because”.

Speech skills: Please describe your child’s speech and any particular difficulties that you’ve noticed. If speech clarity is a concern, please write down some of the words that your child says and how s/he says them e.g. “p” for sheep, “b” for ball, “pull for apple, “babar” for grandma.

Does your child interact well with other children?

Education:(If appropriate)

Play group/ Nursery/ School attended:

Address: / Head Teacher:
Telephone: / Class Teacher:

What additional support does s/he receive?

Describe school placement: type of school, and number of sessions if part time:

What year group is your child in?

What is going well at school? Are there any particular problems?

Reading skills: Does your child read/ recognise written words? Describe skills and reading books if following a scheme.

Speech and Language Therapy:What current provision does s/he have?

What is your Speech and Language Therapist currently working on?

Feel free to copy any relevant letters, target sheets, reports as you wish.

Referral completed by……………………………………Date……………..