Speech and Language Therapy Review Form

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 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

Is an EHCP in place?YesNo

Please provide details of diagnosis (including awaiting/being assessed for, date and by whom) If the family uses more than one language at home, when is each language spoken and to whom? Parent/carer details


Full name(s)
Mobile phone number
Home phone number

Who has parental responsibility?As aboveOther

If other, please provide details If other please specify Please rate the following

	Name of service provider	Contact details	Date of support	Additional information

Please provide an update regarding the below skill areas and any strengths and challenges your child has within these areas:

Speech Sound Difficulties (e.g. are there any difficulties producing a particular sound or unclear speech?) Stammering Use of Language (e.g. are there any difficulties giving explanations or recounting an event?) Understanding of Vocabulary Social communication ( e.g. are there any difficulties joining in with conversations or ‘reading’ social situations?) Understanding figurative, non-literal language (e.g. are there any difficulties understanding complex sentences, banter or implied meaning?) Information processing (e.g. are there any difficulties with speed of processing?) What are your child’s strengths and interests? What are your main concerns at the moment around your child’s communication? What do you hope Speech and Language Therapy can achieve? What is the impact of these concerns from your child’s perspective? For example, do they express or act out frustrations or withdraw from communicating if they find it hard? Any other information you would like us to be aware of or any other changes within the last 12 months?

When students are referred into the Speech Therapy service we hold data about them to help us deliver the right support (e.g. details about their communication skills and 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 be 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 is correct.

Please enter your name* Please enter your email address

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