Speech and Language Therapy Referral

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

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

Pupil's details


First name
Surname
DOB

Home address GP name and address Please provide school year group at Slindon College Parent/carer's details


Full name(s)
Mobile phone number
Home phone number

Who has parental responsibility?As aboveOther

If other, please provide details What is your child's main language? If you family uses more than one language at home, when is each language spoken and to whom? Please tell us if there is any relevant medical history (such as confirmed diagnoses)

Is there a history of communication difficulties (or related diagnoses) in your family?YesNo

If yes, please provide details.

Do you have any current concerns about your child's hearing?YesNo

If yes, please describe the concern When was your child's hearing last checked? (Approximate month and year is sufficient)

Have hearing concerns been raised by a professional?YesNo

If yes, please provide details

Has your child been seen by a Speech and Language Therapist (SaLT) before?YesNo

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

When was your child last seen by a SaLT? (Approximate month and year is adequate.)

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

Please provide their contact details below and please upload or email over copies of recent OT reports

If other, please specify Please complete for each service currently working with the pupil

	Name of service provider	Contact details	Date of treatment	Additional information

Does your child cough/choke after eating?YesNo

Does you child have regular chest infections?YesNo

Please rate how worried you are about your child's communication. (10 being the highest level of concern).

	0	1	2	3	4	5	6	7	8	9	10

What are your main concerns around your child's communication? What impact do these issues have on your child? Does your child show awareness of these concerns? I.e do they express or act out frustrations or withdraw from communicating if they find it hard? What are your hopes for what Speech and Language can achieve?

Data Protection

When pupils are referred into the Occupational Therapy service we hold data about them to help us deliver the right support (e.g. information gathered from family members/professionals). This helps us track the effectiveness of intervention, and ensure high quality. The data is kept securely (in line with the school data policy), and would only be shared with those who need to know.

Parent/carer consent*I give consent for my child to partake in Speech and Language Therapy sessions, including any therapy assessments required. If intervention is implemented I understand that progress cannot be guaranteed. I give consent for information to eb shared with the appropriate agencies where it is in the best interest of my child.Please tick this box to confirm you, as the child's caregiver, completed this form and that the information provided is correct.

Please enter your name* Please enter your email address

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