Children s Speech and Language Therapy Referral Form We see children up to their 18 th birthday Referral Checklist done: Fill in this form and send with the referral checklist Fill in the Referral Checklist then fill in this form. Go to: www.barnsleyspeechtherapy.co.uk You must fill in pages1& 2 and tell us why you are referring. If you don t we will send the form back. Child s Name Male/Female Address Home School/Nursery/Playgroup/Childminder (Please give name) Ethnicity NHS number Mobile Religion Date of Birth Postcode Other First Language Languages If the family need an interpreter, what language and dialect: Language GP Practice Dialect Health Visitor / School Nurse Consultant / Associate Specialist Medical Diagnosis List other professionals who see this child: Health Centre / Do you know about any safeguarding concerns? YES NO If yes, who will give us more information? Name number Do you know about any safety risks to staff E.g. communicable infection, risk of violence and aggression? YES NO If yes, who will give us more information? Name number
For us to support families getting to appointments tell us if the parent / legal guardian has any other needs e.g. wheelchair access, reading and writing problems, learning difficulties? Tell us what help they need: Referrers need to get consent before referring. Usually this is from the person who has parental responsibility. Sometimes the child can give consent. When a child gives consent, you must get their permission for us to share information with their parent / legal guardian. Sign below. A person who can give consent agrees to the referral. If the person giving consent is a child, choose one of the following: They do agree to their parent / legal guardian knowing about the referral They do not agree to their parent / legal guardian knowing about the referral SPEECH AND LANGUAGE REFERRALS The person who gives consent knows: 1. They will get a letter about how to make an appointment. They will need to phone up within 3 weeks. If they do not ring or do not attend appointments they will be discharged. We will tell the child s GP, the referrer and professionals who see the child. 2. You usually need to practise Speech and Language Therapy activities everyday. It might not be the right time for a referral if they cannot agree to this. EATING / DRINKING REFERRALS Child in hospital: If the parent / legal guardian has given consent they also give permission for us to see their child if they are not there. Child in other location: You have told the person who gives consent that we will phone them within 10 working days of getting the referral. The referral agent may need to act in the interests of the child s health and well being if the child does not attend. Signed: Name: Designation: Date: Address: number: Return to: Children s Speech and Language Therapy Department, New Street Health Centre, Upper New Street Barnsley, S70 1LP Or email to: childrensspeech.therapy@swyt.nhs.uk 2
Read all the statements below. Tick ( ) any that are relevant. Go to the sections you have ticked. Fill them in. The child goes to a Childminder, Playgroup, Nursery or School This is a re-referral (Do not use for eating / drinking referrals) Go to SECTION 1 Go to SECTION 2 The child has difficulty with eating / drinking Go to SECTION 3 The child has difficulty understanding / using language Go to SECTION 4 The child stammers / stutters Go to SECTION 5 The child has difficulty pronouncing sounds in words Go to SECTION 6 SECTION 1 CHILDREN WHO GO TO A CHILDMINDER, PLAYGROUP, NURSERY OR SCHOOL Send the Placement Information letter to the child s placement. This is part of the referral. This can be printed from our website www.barnsleyspeechtherapy.co.uk. Date the Placement Information letter sent: 20 3
SECTION 2 RE-REFERRAL The child has difficulty with: Understanding / Using language Stammering / Stuttering Pronouncing sounds in words Please give details here: Why are you referring again? The child has previously been discharged for non-attendance Please give us the following information: Why the family did not attend / make an appointment What will help the family come to appointments e.g. send a copy of the appointment to you, send them a text reminder The child has now made progress and reassessment is needed The child has not made the expected progress The child has had a change of setting or teaching assistant Other 4
SECTION 3 EATING / DRINKING DIFFICULTIES We will contact the family within 10 working days of getting the referral. We usually do a phone appointment to find out more about the child s difficulties and assess risk. Is the child in hospital? Hospital name Ward What are you worried about? Please attach a Paediatrician s report if you have one. Medical staff may want to attach a copy of their clinical summary notes. 5
SECTION 4 DIFFICULTY UNDERSTANDING / USING LANGUAGE A child who has difficulty understanding / using language may not: do as you have asked them to do. use any / many words. put words together to make a sentence. We do not have a service for children who have generalised learning difficulties and whose speech and language skills are broadly in line with their general learning level. Only refer if there are other difficulties over and above those due to their generalised learning difficulties. Do you think the child may have a social communication difficulty / is on the autistic spectrum? Have you have discussed this with the parent / legal guardian? Have you made a referral to a Paediatrician? If no, make a referral to a Paediatrician. Does the child have generalised learning difficulties? If yes, only refer if there are other difficulties over and above those due to their generalised learning difficulties. You must give details of the child s current learning levels. What are you worried about? What problems does this cause the child? Send any reports you have from other professionals. 6
SECTION 5 STAMMER / STUTTER Stammering is the same as stuttering. Stammering is: Repeating words or sounds e.g. I I I I want or d d d dog. Stretching out sounds e.g. sssssssausage. Getting stuck and no sound coming out. Our website www.barnsleyspeechtherapy.co.uk gives general advice about stammering for parents and professionals. Ask the parent / legal guardian to rate on a scale of 1-10 the severity of the stammer: not severe 1 2 3 4 5 6 7 8 9 10 very severe Ask the parent / legal guardian to rate on a scale of 1-10 their level of anxiety about the stammer: not worried 1 2 3 4 5 6 7 8 9 10 very worried SECTION 6 DIFFICULTY SAYING SOUNDS IN WORDS A pronunciation difficulty is when a child s speech is not clear and they are difficult to understand. Our website gives general advice for children with pronunciation delay www.barnsleyspeechtherapy.co.uk What are you worried about? Tell us what sounds are difficult for the child to say. What problems does this cause the child? Send any reports you have from other professionals. 7