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Children’s speech and language therapy – referral form

Children’s speech and language therapy – referral form

Section 1

This referral must be completed in conjunction with a parent/carer. Please see referral guidance for information on making a referral. If you are unsure about making a referral, please contact our service to discuss your concerns with a member of our team.
Any incomplete forms will be returned to sender for completion.
Speech and Language Therapy input is only effective if someone is available to carry out the recommendations. This referral will only be considered if someone is available to plan with the SLT and carry out programmes of work. Please provide the name of the person(s) who will support the SLT recommendations (e.g. family member, other carer, health professional, or member of staff in the educational setting).
Is this referral in relation to the child’s

Section 2

DD slash MM slash YYYY
Address(Required)
Permission to contact by text(Required)
Safeguarding information (if applicable)
Is this a looked after child/young person
Is there a child protection plan?

Section 3

Is an interpreter required for the child/young person?(Required)
Is an interpreter required for the parent/carer?(Required)
Are the child/young person’s language skills the same in all languages?(Required)

Section 4

Medical information:

Section 5

Please indicate the difficulties the child/young person is having:
Attention and listening(Required)
Understanding spoken language(Required)
Using Spoken Language(Required)
Use of speech sounds(Required)
Social Interaction and Play(Required)
Stammering(Required)
Voice/vocal quality(Required)
Eating, drinking and swallowing(Required)

Section 6

(e.g. specific individual strategies or attending available groups such as ‘Tots Talking’, Ready to Grow’, ‘Ready to Learn’, ‘NELI’, ‘Talkboost’, Fluency groups, etc.).

Section 7

Has the child been referred to Speech and Language Therapy before?(Required)

Section 8

Learning/developmental progress
How is the child /young person making progress against expected levels?
Does the child/young person access any additional support?
Have you sought any professional advice to support this child’s learning? e.g. Educational Psychology, Advisory Teacher
Max. file size: 50 MB.
Does the child/young person have an EHCP?
Does the child/young person have a support plan?

Section 9

(Where 0 is none and 7 is significant)

Section 10

Referred by
Contact Address(Required)
DD slash MM slash YYYY
If you are an education professional, please tick to confirm that this referral has been discussed with your SENDCo
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