referral form: speech and language therapy … · referral form: speech and language therapy...

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Page 1: REFERRAL FORM: SPEECH AND LANGUAGE THERAPY … · referral form: speech and language therapy general information nhs no: surname…………………………………………….dob

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 *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)

REFERRED BY:

Name……………………………………………Title…………………………………. Address……………………………………………………………………………………………………………………….. ……………………………………………………………….Date..………..…………………… Telephone no: …………………………………………………………..…………..

Page 2: REFERRAL FORM: SPEECH AND LANGUAGE THERAPY … · referral form: speech and language therapy general information nhs no: surname…………………………………………….dob

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

EDUCATIONAL INFORMATION Does the child have support in their pre-school setting e.g. nursery, playgroup? Please explain further: …………………………………………………………………………………………. …………………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………………..

Ethnicity White Black or Black British 01 British 12 Caribbean 02 Irish 13 African 03 An other white background 14 Any other Black background within this group Mixed Other ethnic group 04 White & Black Caribbean 15 Chinese 05 White & Black African 16 Any other ethnic group 06 White & Asian 07 Any other mixed background Asian or Asian British Please note: the above ethnic origin classification is based on advice by the 08 Indian Commission for Racial Equality. 09 Pakistani 10 Bangladeshi 11 Any other Asian background within this group

Please return this form to: The Secretary, Speech and Language Therapy Service, Kirklees PCT, Dewsbury Health Centre, Wellington Road, Dewsbury WF13 1HN. Tel 019243 351546 For office use only: Date referral received ………………………………….