SPEECH AND LANGUAGE THERAPY REFERRAL

When Considering Referral to Speech and Language Therapy – Child in School

Please consider the following questions before you fill in the referral form, to make sure you need to proceed with the referral. The school’s visiting SLT will be happy to discuss the issue in general terms before you refer.

Has the pupil been known to SLT before?

No Yes Don’t know

If yes, do any previous reports in the school records address your current questions?

Have you consulted the:

Entitlement Document? Speech and Language Friendly Schools Guidelines?

Have you tried any of the suggested strategies?

Have you tried language related IEP targets?

Have other professionals given advice?

Have you included the pupil in any ongoing school-based language interventions (e.g. Talking Partners)?

What further information are you looking for from SLT?

If we do receive a referral the pupil will be assessed in one of the following situations:

If the difficulty is with understanding or using language, or with social communication, we will see the child at school.

We will need information from the family. If you proceed with the referral, please ensure the family understands that we will need to take a Case History from them. Ideally we would meet the family at school. Please note here if the parents have any restrictions about times they can meet us.

If the difficulty is with pronunciation or stammering, we will invite the child to a clinic.

We will need the family to bring the child for assessment and to any subsequent appointments for us to address the problem with them. Although we will try to be flexible about timings, our clinics are held at specific times, and appointments may need to be within school hours.

BG/CW/F&Tdisk3/Sdrive/05/11/12. John Gilbert

Board Director Commissioning (DSC/DASS)

REFERRAL FOR SPEECH AND LANGUAGE THERAPY ASSESSMENT (CHILDREN)

Please complete in BLOCK CAPITALS

Date:…………………………….

Full Name: …………………………………………………………...…… Sex: ……………

Surname of carer, if different: ……………………………………………………………….

Address: ………………………………………………………………………………………..

Postcode: ……………………Telephone Number: …………………………………………

Other phone contacts in case of need to cancel: …………………………………………..

Date of birth: ……………………….…G.P.Practice………………………………………….

First Language (If not English): ……………………………………………………………….

Interpreter Required? Yes / No

Pre-school / School

Goes to pre-school / school at:………………………………………………………………

Sessions attended: …………………………………………………………………………..

Class Teacher / Key worker:…………………………………………………………………

SENCO: ……………………………………………………………………………………….

School year: ……………………………………………………………………………………

SEN: None Graduated Response Undergoing assessment for EHCP

Statement EHCP

If pre-school child:

Preferred school: ………………………………………………………………………………

School start date: ………………………………………………………………………………

Reason for Referral: (if this referral is from pre-school or school staff, complete pages 3 & 4 in as much detail as possible instead of this section and attach your BRISC) ……..………………………………….…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

John Gilbert

Board Director Commissioning (DSC/DASS)

2)

Other Information:

Premature Delayed overall development Delayed symbolic play development Child Protection plan / Child in need No recent progress in speech/language development Family history of speech / language difficulties, learning difficulties, ASD etc. Has older sibling(s) (i.e. not first born) Not in nursery / limited opportunities for interaction Glue ear /hearing difficulties

Most recent hearing test date & result: ………………………………………………………

Other Professionals Involved: ……………………………………………...……………..…………………………………………………………………………………………………………………………………………………………………………………………………………

Other Information: ………………………………………………………..…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Bristol Surveillance of Children’s Communication (BRISC)

BRISC Used Yes No (If Yes, please attach a copy)

Details of referrer

Name: ……………………………………………………………………………………………Designation: ………………………………………………………………………………..…...Address: …………………………………………………………………………………..…….Telephone Number: ……………………………………………………………………………

(Name of Health Visitor: ………………………...………….. Base: ………………………)

Please sign to confirm that you have obtained parents / carers’ permission for this referral, and ask them to sign if at all possible. We also require a completed ‘parents’ preferences form’.

Do parents have use of a car to get to appointments?

Parent / Carer’s Signature: ……………………………………. Date: ……………………

Referrer’s Signature: ……………………………………..…… Date: ………..…………..

Please send completed form and BRISC to:

Speech and Language Therapy Services, The Salt Way Centre, Pearl Road, Middleleaze, SWINDON SN5 5TD John Gilbert

Board Director Commissioning (DSC/DASS)

TEL: (01793) 4667903)

Information for Speech and Language Therapist from school / pre-school

1) Nature of difficulty with communication and effect on accessing the curriculum in terms of:

a) Child’s understanding / comprehension of spoken language?

b) Expressing him / herself in spoken words and sentences?

c) Pronunciation (speech sound errors); clarity of speech?

d) Stammering?

e) Interaction with other people?

John Gilbert

Board Director Commissioning (DSC/DASS)

4)

2) Child’s strengths?

3) Please say what you need from this Speech and Language Therapy assessment

4) What support arrangements are available?(Name of Support Assistant, if applicable)

Signed:

Parent: ………………………………………………………..

Class Teacher: ………………………………………………..

SENCO: ………………………………………………………

REFERRALFORM(25/01/06)Updated:23/04/13.

John Gilbert

Board Director Commissioning (DSC/DASS)

Parents’ Personal Views

The Speech and Language Therapy Department would like to keep improving its service. We would be grateful if you would help us by filling in these details.

Name of Child: ..............................…………………........ D.O.B.: ............................

1) Please describe what is concerning you about your child’s communication.

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2) What questions would you like answered?

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Preferences

In order to avoid wasting appointments we would like to take your needs into account. While we won’t always be able to meet your needs exactly, we will try: Please put down any times, days or dates we should try to avoid when planning any future appointments.

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Culture/Religion

We would like to be sensitive to your culture or religion. Please put down any details you would like us to know.

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...................................................................................................................................... John Gilbert

Board Director Commissioning (DSC/DASS)

Therapists Initials:Caseload:

Speech & Language Therapy ServicesSalt Way Centre

Pearl RoadMiddleleaze

Swindon SN5 5TD

Tel: (01793) 466790 Fax: (01793) 873490

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Languages

We would like to be sure that we are communicating with all groups in our population. Please put down which languages are used in your home.

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Would you like the help of an interpreter, or translation of any written material?

Yes No If Yes, which language? ................................................

EthnicityTo help us know whether we are reaching all groups in our population, please indicate the child’s ethnic group, as defined by the Office of Population Census and Surveys.

a) White - British- Irish- Other white background

b) Mixed- White & Black Caribbean- White & Black African- White & Asian- Any other mixed background

c) Asian or Asian British- Indian- Pakistani- Bangladeshi- Any other Asian background

d) Black or Black British- Caribbean- African- Any other Black background

e) Other Ethnic Groups- Chinese- Any other ethnic group

Signature: ……………………………………… Date: …………………………….

John Gilbert

Board Director Commissioning (DSC/DASS)

In case we need to cancel at short notice, please give contact numbers so we can let you know: …………………………………………………………………………………….

CMcN/GP/23/09/15.

John Gilbert

Board Director Commissioning (DSC/DASS)