Children’s Speech and Language Therapy Referral Form

Child or young person’s details
Name Click here to enter text.	DOB Click here to enter text.
NHS number Click here to enter text.	Gender Choose an item.
Address Click here to enter text.	Nursery/School/College Click here to enter text. ☐ full time ☐ part time
Parent 1 Name Click here to enter text. Parent 1 Phone number Click here to enter text. ☐ address as above? If not provide here: Click here to enter text.	Parent 2 Name Click here to enter text. Parent 2 Phone number Click here to enter text. ☐ address as above? If not provide here: Click here to enter text.
Interpreter required? Choose an item. Language spoken Click here to enter text.	Is the child or young person a Hackney looked after child? yes☐ no ☐

Communication	Tick any that apply	Please give details of your concerns: (referrals with no/limited information will not be accepted)
Difficulty understanding	☐
Difficulty using words and sentences	☐
Difficulty with social skills	☐
Play	☐
Clarity of speech	☐
Stammering	☐
Voice Quality e.g. hoarse or croaky	☐
Eating, drinking and Swallowing	Tick any that apply	Please give details of your concerns: (referrals with no/limited information will not be accepted)
Child has signs of difficulty when eating/drinking e.g. Coughing / gagging / watery eyes	☐
Child has repeated chest infections	☐
Faltering growth/failure to thrive	☐
Oro-motor difficulties impacting on chewing/manipulating food in the mouth	☐
Does the child/young person need food/drink textures to be altered in order to swallow safely?	☐
Any difficulties sucking e.g. breast/bottle feeding?	☐

Has the parent/carer consented to this referral?	Yes ☐	No☐

Please indicate which days the parent is able to attend:

Monday ☐	Tuesday ☐	Wednesday ☐	Thursday ☐	Friday ☐

Referrer’s name	Telephone Number
Profession	Address
Date form completed:Click here to enter a date.