SCHOOL REFERRAL FORM: SPEECH AND LANGUAGE THERAPY
GENERAL INFORMATION
NHS NO:
Surname…………………………………………………………………
DOB……………………………..
First name ..……………………………………………………………
Male/Female……………...
Parent’s surname (if different from child) .….…………………………………………….. Address..……………………………………………………………………………………………………………… …………………………………………………………………………… Postcode……..………………………. Home telephone ……………………….. Mobile
(parent/carer’s)…………………….………..
School…………………………………….Contact person in school………………………………… GP …………………………………………………………………………………………………………………………. ADDITIONAL INFORMATION: Home language…………………………..…..Interpreter required for parents…YES/NO Other agencies involved (if any)………….…………………………………………………………………… Any hearing concerns?
(If yes, please specify)……………………………………………………………….
EDUCATIONAL INFORMATION: Code of practice stage:
□ Early Years Action □ School Action □ Statement
□ Early Years Action Plus □ School Action Plus
Please tell us what support is available in school for the child : Support in the classroom: Please indicate your current areas of concern: Receptive language Stammering (understanding) Expressive Language Clarity of speechof work: 1:1 support to deliver speech and language programme Social communication
Voice
Please indicate your current areas of concern: Receptive language Stammering (understanding) Expressive Language Clarity of speech Social communication
Voice
Other (please specify)
Please give us some more information about the child’s communication difficulty and explain how it is affecting them academically and socially
What strategies are currently being used in school to support the child’s communication?
REFERRAL
Reason for referral:
What specifically would you hope to happen as a result of the speech and language therapy assessment?
Has the child been referred to speech and language therapy before? YES/NO ……………………….. If yes, please give details:
Referred by: Name……………………………………………Designation….. ……………………. Address…………………………………………………………………………………. ……………………………………………………………………………………………...Date..………..…………. Telephone no: …………………………………………………………..…………..
CONSENT
*Please note, parental signatures are required.*
I give consent for my child to be referred to speech and language therapy ……………………………………………………. (Parent/Guardian please sign) I give consent for information related to my child’s therapy to be shared/ discussed with health/education/other colleagues ……………………………………………………… (Parent/Guardian please sign) I give consent for information to be shared about the dates and times of my child’s appointments ……………………………………………………… (Parent/Guardian please sign)
Please note, this form may be returned if not all relevant sections have been completed. Please return this form to: The Secretary, Speech and Language Therapy Service, Kirklees Community Healthcare Services, Dewsbury Health Centre, Wellington Road, Dewsbury WF13 1HN. Tel 019243 351546 For office use only:
Date referral received ………………………………….