Communicate SLT Community Interest Company (CIC)

Request for Paediatric Speech and Language Therapy (SLT) Services

Referrer (the referrer is the person completing this form)

PLEASE READ BEFORE COMPLETING THIS FORM.

It is assumed that the person completing this form either is the parent or carer or the person with parental responsibility for the referred child/young person.

If you are not, please ensure that you have sought consent to complete this document on behalf of the person who has parental responsibility.

Please also ensure the section below has your personal details in it – please do not complete the Referrer section with details which are for a company, professional body or the name of the child/young person as this will invalidate the request for services.

Referrer Forename *
Referrer Family name *
Referrer Role or relationship with the child/young person *
Referrer Contact email *
Referrer Contact telephone number *
Find address
Referrer Address *
 
Referrer Town *
Referrer County *
Referrer Country *
Referrer Postcode *

Consent

Please remember that you must either be the parent or carer or the person with parental responsibility for the referred child/young person to answer these. If you are not, please ensure that you have sought consent to complete this document on behalf of the person who has parental responsibility before you proceed. From now on, we will use the term referrer assuming you are one of the above named individuals or someone who has consent to refer.

I the referrer, confirm that I either have parental responsibility for or permission from the person/people who do, to complete this Request for Paediatric Speech and Language Therapy (SLT) Services form?*
I the referrer, confirm that I either have parental responsibility for or permission from the person/people who do, and that relevant details can be shared by Communicate SLT CIC with other professions involved in the referred child/young person’s care/education?

This question is only for those who are making a request for services for a child/young person who was, at 30 October 2023, on Chatterbug Ltd’s caseload. If you were not, please answer N/A.

I the referrer, confirm that I either have parental responsibility for or permission from the person/people who do and, if it is required to do so, Communicate SLT have their permission to provide the SLT services their child/young person requires and to add any data Chatterbug has supplied to a patient record which we will hold?
Do Communicate SLT CIC have your permission to contact you in the future with relevant information?

Child/young person's details

Child/young person's forename*
Child/young person's family name *
Child/young person's date of birth (DOB) *
Child/young person's gender at birth *
Child/young person's gender identity
Child/young person's ethnicity
Does the child/young person have an Education, Health and Care Plan (EHCP) in place? *

Parent/carer 1 (main parent/carer)

Parent/carer 1's forename *
Parent/carer 1's family name *
Parent/carer 1's relationship to the child/young person *
Does this person have parental responsibility for the referred child/young person *
Find address
Parent/carer 1's home address *
 
Parent/carer 1's town *
Parent/carer 1's county *
Parent/carer 1's country *
Parent/carer 1's postcode *
Parent/carer 1's telephone number *
Parent/carer 1's email address *

Parent/carer 2 (Optional)

Parent/carer 2's forename
Parent/carer 2's family name
Parent/carer 2's relationship to the child/young person
Does this person have parental responsibility for the referred child/young person
Find address
Parent/carer 2's home address
 
Parent/carer 2's town
Parent/carer 2's county
Parent/carer 2's country
Parent/carer 2's postcode
Parent/carer 2's telephone number
Parent/carer 2's email address

Child/young person's address (if different to the above)

Which of the above addresses does the child reside at?
Find address
Child/young person's address *
 
Child/young person's town *
Child/young person's county *
Child/young person's country *
Child/young person's postcode *

Support with Appointments

If your child/young person has a preferred name, please detail this here. *
Please be advised that all patient records and correspondence will – unless a legal change of name has occurred at which point we require paperwork to change this formally – will be in their legal name.
We will do our best to refer to your child/young person informally by their preferred name.
Is an interpreter needed to converse with parent/carer 1 or the person who has parental responsibility *
If yes, what language should the interpreter speak
Is an interpreter needed to converse with the child/young person? *
If yes, what language should the interpreter speak
Could the parent/carer or the person who has parental responsibility struggle to read and understand appointment letters written in English? Please be advised if you answer ‘Yes’ to this question, Communicate SLT will assume you have consent from them for us to send copies of appointment letters to a professional named by the you, to support interaction with us *
If yes, do you as the referrer confirm the parent/carer consents for copies of appointment letters to be shared with a professional to support attendance? Please provide this professional's name here and ensure that their full contact details are entered below in the Agencies Involved section.

Educational setting details

Educational setting type *
Educational setting name *
(If you have answered 'Does not attend an educational setting' in the question above, please share more details here if you can)
Find address
Educational setting address
 
Educational setting town
Educational setting county
Educational setting country
Educational setting postcode
Person to contact at educational setting
Educational setting email address (if known)
Educational setting telephone number (if known)
Year group/class (please enter N/A if this does not apply) *
What times and days of the week does the referred child/young person usually attend their educational setting?

Tick all that apply
Day AM PM
Monday
Tuesday
Wednesday
Thursday
Friday
Does the referred child/young person attend the educational setting term time only or all year round? *

Existing family support

Is there a Multi-Agency Plan (MAP), Early Help Assessment (EHA) or Early Help Plan (EHP) in place? *
Is there a child/young person protection plan in place? *
Is there a child/young person in need plan in place? *
Is the child/young person in the care of the Local Authority? *

Existing diagnoses

Does the child/young person have a current diagnosis of any of the following

Please share details of anything else you feel might be relevant from the child/young person’s medical history and let us know what medication and/or physical and/or mental health support is already in place. You may wish to share with us information around vision tests, hearing tests, allergies, physical needs for example.

ADHD *
Autism *
Cerebral Palsy *
Cleft Lip and Palate *
Hearing Impairment *
Learning Disability *
Selective Mutism *
Social, Emotional and Mental Health Needs (SEMH Needs) *
Other
Please share any other relevant medical history and support/medication in place
(e.g. recent hearing, vision test, allergies, epilepsy, mental health, physical needs, other)

Details

Existing agencies involved

GP practice name
Find address
GP address *
 
GP town *
GP county *
GP country *
GP postcode *
Speech and Language Therapy *
If yes, please provide the Therapist's name and contact details
Occupational Therapy *
If yes, please provide the Therapist's name and contact details *
Physiotherapy *
If yes, please provide the Therapist's name and contact details
Paediatrician *
If yes, please provide the Paediatrician's name and contact details
Social Services *
If yes, please provide the name of your contact at Social Services and their contact details
Advisory Teachers *
If yes, please provide the Teacher's name and contact details
Education Psychology *
If yes, please provide the Psychologist's name and contact details
CAMHS *
If yes, please provide details of the CAMHS service supporting the child/young person
Has the Special Educational Needs Co-Ordinator (SENCo) in an educational setting been informed of this referral? *
Other – please give as much detail as possible, including the name, profession and postal address of the professional to whom you require Communicate SLT to send copies of appointments to, should you have indicated a language barrier earlier in this referral.
Has this child/young person been referred to speech and language therapy services previously? *
If you have answered yes or don’t know, please provide as much detail as you can here. You may be able to advise who the therapy provider was, when the therapy took place, what practices you were asked to put in place for example.

Areas of Concern

What is your main area of concern? (Score 0 for no concerns at all and 5 for severe difficulties in this area)

Attention and Listening *
e.g. poor concentration, highly distractable, not able to focus on adult led activities for an age appropriate length of time
Understanding Language *
e.g. not able to follow instructions, answer questions, or understand concepts at an age appropriate level
Expressive Language (talking) *
e.g. limited vocabulary development, difficulties using age appropriate spoken grammar/sentence structure, word finding difficulties
Speech/Articulation *
e.g. unclear speech, incorrect or limited speech sounds used
Social Skills *
e.g. difficulties with turn taking, keeping to topic, literal interpretation of language, limited awareness of other children/adults, difficulties with friendships
Play *
e.g. not engaging in pretend/imaginative play at an age appropriate level, shows only repetitive/copied play, limited interests, not able to join in with shared play activities
Voice *
e.g. persistent hoarse/weak voice quality, vocal nodules, excessively nasal voice quality
Dysfluency *
e.g. Stammering/Stuttering, not being able to ‘get words out’ with ease
Do you have any other areas of concern?
Describe why these are areas of concern for you
What interventions/support have been or are currently in place for the child/young person

Details *

WellComm assessment (if available)

Please advise if you can provide either an Early Years or Primary WellComm Score, or neither

NB. If you confirm any WellComm assessment is available, please be advised we expect to see all scores and details of which questions the child/young person got wrong, from and including their age appropriate section back to the section that the WellComm score shows green. If you cannot supply this detail in full, please advise ‘Unable to complete a WellComm score’ and the Communicate SLT CIC team will contact you in due course to assist with this*

Supporting Documentation

Please attach any relevant documentation Communicate SLT CIC might find useful to support to this referral. If possible, please ensure each document has in its title the referred child/young person’s initials and date of birth only. Thank you.

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