Communication Referral Form (Non-Education)

If you need help to read and complete this referral form, please contact the department on 01625 661881.

PLEASE ENSURE ALL REQUIRED QUESTIONS ARE COMPLETED

If these questions are not completed, an error message will appear when you attempt to submit the form, and any files you have uploaded throughout the form will be deleted and will need to be reuploaded.

A) Referrer Details

Name Required

Role Required

Contact address Required

Email address Required

Contact number Required

Would you like to be notified when an opt in letter is sent out? Required

B) The Child

Child's full name Required

DOB Required

Contact address

Address line 1 Required

Address line 2

Town Required

County Required

Postcode Required

NHS number

Contact numbers Required

C) Professionals Involved

GP - please note we do not routinely accept referrals for out of area GPs, we will only accept such referrals who are transferring into the area with SALT provision stated on their EHCP Required

School/nursery

Has this child been seen by SLT before (to your knowledge)? Required

Please detail other professionals known to the child / young person Required

D) Family Information

Name of person with parental responsibility Required

Please provide contact details of person with parental responsibility if different to section B

Is the child / young person subject to any of the following? Required

Early Help

Child in Need

Child Protection Plan

Looked After Child

None

If yes, please provide details (including name, contact details, the key person) Required

What languages are spoken at home? Required

What is the main language spoken by the child or young person? Required

Will the parent / guardian need an interpreter for the initial appointment? Required

Any additional information about the child / family circumstance we should be aware of? (including any parental support needed to access our service) Required

E) Referral Information

We need to know the reason you wish to refer this child. Do you have concerns about any of the following?

Please upload any relevant documentation to support this referral

Attention and listening - the child's developmental stage of listening and attention Required

Social communication and interaction - the child's ability to interact (verbally or non-verbally) with peers Required

Understanding of spoken language - the child's ability to understand and interpret what they are told verbally Required

Expressive language - the child's ability to turn their thoughts/ideas into spoken language, for example - choosing the words needed, putting them in the correct order and using the right grammar. Required

Speech sounds/speech clarity - the sound a child uses and how clear they are relative to age expecations. Please note this refers only to speech and not to their reading/literacy. Required

Voice - persistent hoarse/weak voice or episodes of loss of voice without apparent cause. Confirmed/suspected vocal nodule. Required

Stammering/stuttering – involuntarily repeating parts of words, stretching out sounds, or blocking. Sometimes resulting in visible tension or effort. Required

If you have answered yes to any of the above, please provide further details including what has been tried already

F) Consent

I am the parent/carer/legal guardian of this child Required

If you have answered yes to the above question, please tick below to give your consent

I confirm I have parental responsibility for the child being referred. I consent to this referral and to being contacted by post/phone by the SLT service

I consent to my child’s information being shared with other professionals when it is the child’s best interests (for example school/nursery, GP)

I understand that a digital record will be kept of any appointments, letters, reports, care plans. This information is visible to other professionals involved in my child’s care

I understand that the SLT department may contact my child/young person's educational setting for further information to support this referral

I am a healthcare professional Required

If you have answered yes to the above question, please tick below to give your consent

I confirm I have obtained informed verbal consent from the person with parental responsibility for the child being referred. They consent to this referral and to being contacted by post/phone by the SLT service

I have explained that the child’s information will be shared with other professionals when it is the child’s best interests (for example school/nursery, GP) and they consented to this

I have explained that a digital record will be kept of any appointments, letters, reports, care plans. This information is visible to other professionals involved in my child’s care

I have explained that the SLT service may contact the child/young person's education setting to obtain further information to support this referral

PLEASE ENSURE ALL REQUIRED QUESTIONS ARE COMPLETED

All referrals will be rejected if parental consent is not evident.

I agree to the privacy policy

Communication Referral Form (Non-Education)

PLEASE ENSURE ALL REQUIRED QUESTIONS ARE COMPLETED

A) Referrer Details

B) The Child

C) Professionals Involved

D) Family Information

E) Referral Information

F) Consent

PLEASE ENSURE ALL REQUIRED QUESTIONS ARE COMPLETED

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Communication Referral Form (Non-Education)

PLEASE ENSURE ALL REQUIRED QUESTIONS ARE COMPLETED

A) Referrer Details

B) The Child

C) Professionals Involved

D) Family Information

E) Referral Information

F) Consent

PLEASE ENSURE ALL REQUIRED QUESTIONS ARE COMPLETED

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