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REFERRAL FORM: SPEECH AND LANGUAGE THERAPY GENERAL INFORMATION

NHS NO:

Surname…………………………………………….DOB……………………………. First name ..………………………………………………………….M/F……………. Parent’s surname (if different from child) .….………………………………………. Address..………………………………………………………………………………… ………………………………………………………….Postcode……..……………… Home telephone ………………… Mobile (parent/carer’s)…………………….……… School………………………………………………GP………………………………. ADDITIONAL INFORMATION: Home language…………………………..…..Interpreter required…….…YES/NO Other agencies involved (if any)…………. …………………………………………… Any hearing concerns? (If yes, please specify)…………………………………………….

CONSENT required.

* Please note, parental signatures are

*

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)


PTO REFERRED BY: Name……………………………………………Designation….. ……………………. Address…………………………………………………………………………………. ……………………………………………………………….Date..………..…………. Telephone no: …………………………………………………………..…………..

REASON FOR REFERRAL: …………………………………………………………………………………………… . …………………………………………………………………………………………… . …………………………………………………………………………………………… . …………………………………………………………………………………………… . Has speech and language therapy been offered before?..................................... …………………………………………………………………………………………… ..

EDUCATIONAL INFORMATION

□ Early Years Action □ School Action □ Statement

□ Early Years Action Plus □ School Action Plus

Does the child have support in school?............................................................... …………………………………………………………………………………………… Please return this form to: The Secretary, Speech and Language Therapy Service, Kirklees PCT, Dewsbury Health Centre, W ellington Road, Dewsbury W F13 1HN. Tel 019243 351546


For office use only:

Date referral received ………………………………….


http://www.kirklees.nhs.uk/fileadmin/documents/SALT/Referral_form_pre-school