Feeding and Swallowing Referral Form :: East Cheshire NHS Trust

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

B) The Child

Child's full name Required

DOB Required

Contact address

Address 1

Address 2

City

State/Province

Country

Postal Code

NHS number

Contact numbers Required

*In-patients only - details of current ward*

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

Please provide details of other professionals known to the child/young person

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

D) Family Information

Name of person with parental responsibility Required

Contact details of person with parental responsibility if different to those in section B

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

Which languages are spoken at home? Required

What is the main language spoken by the child/young person at home? Required

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

Please provide any additional information about the child/family circumstances that we should be aware of (including any parental support to access our service)

E) Referral Information

Please detail any relevant medical history (include allergies, development diagnosis and current health status) Required

Please attach relevant documentation to support the referral

What is the main area of concern? Required

How long have there been concerns? Required

What is the current method of nutrition? Required

Are there any concerns regarding weight? Required

If you have answered yes to the above question, please detail concerns.

Describe current types of food/drink taken (describe daily oral intake, consistencies of food/fluid and modification need, any thickener use) Required

If yes to any of the above, please provide details.

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 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 am an educational professional (for example a Senco or nursery Senco) Required

If you have answered yes to the above question, please download a parental consent form by clicking here.

Complete this form with the person who has parental responsibility, and upload below

PLEASE ENSURE ALL REQUIRED QUESTIONS ARE COMPLETED

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

I agree to the privacy policy

Feeding and Swallowing Referral Form

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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Feeding and Swallowing Referral Form

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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