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Speech and Language Therapy Referral

This form is confidential and will only be used by the intended recipient for information purposes.

It is possible for you to save this form in order to complete it at a later stage. To do so please provide your email address at the end of the form before clicking the save button.

Slindon College's Occupational Therapy Team are members of Royal College of Speech and Language Therapists and registered with the Health and Care Professions Council.

First name
Full name(s)
Mobile phone number
Home phone number
Who has parental responsibility?
Is there a history of communication difficulties (or related diagnoses) in your family?
Do you have any current concerns about your child's hearing?
Have hearing concerns been raised by a professional?
Has your child been seen by a Speech and Language Therapist (SaLT) before?

If no, please move on to the next page. If yes, please continue below.

Are you happy for us to contact your child's previous SaLT?