Child's Details

If contact details are incorrectly input where mandatory the referral cannot be processed

Childs Name *

Parents/Carers Name *

Date of Birth *

NHS Number *

Religion

Child's Current Address *

Postcode *

Telephone Number *

Parent/carer email *

Parent's contact details including mobile phone number

Ethnicity

Next of Kin

Overseas visitor? *

Yes

GP Name *

Paediatrician or Consultant name

Is the child's main spoken language English? *

Yes

Is an interpreter required for the parent/carer? *

Yes

If yes, please state language *

Are there any communication needs for this child or their parent/carer? For example, related to learning disabilities or autism or due to impaired sight/ hearing or any other reason/s. *

Yes

What might be helpful when communicating with this child or their parent/carer? *

Consent for contact by email *

Yes

Referral discussed with parents *

Yes

Do parents consent to referral? *

Yes

Patient consented to information sharing? *

Yes

Please tick to confirm that the parent/carer consents to their child receiving assessments and interventions, as is appropriate to this referral

The parent/carer should be aware that if at any point they do not want further treatment or interventions, they must inform their clinician:

Name of School/Nursery

Does the child/Young person have an MSP (My Support Plan)? *

Yes

Does the child/Young person have an EHC (Education & Healthcare) Plan? *

Yes

Diagnosis/Medical History/Medications/Allergies

Any recent or history of chest infections *

Are there any current safeguarding concerns regarding this child and their family? *

Yes

Referrer Name *

Referrer Address *

Referrer Email *

Referrer Contact Number *

Optional Attachment

(Optional) - Please attach any clinical letters/any other relevant information Upload file

Referral

Any other services/professionals involved? Include Health/Education/Early Years SEN/social care

Any concerns regarding growth and/or weight? Please detail here

Please provide supporting evidence of recent observation of feeding including any risk signs/red flags noted.

Please detail the presenting difficulties and concerns including any appropriate information regarding foods offered/food consistencies/bottle/cup drinking/utensils.

Please detail targeted advice and support previously given and ipmact of this.

Reason for feeding/swallowing referral *

Information Required

Please provide information regarding the outcome of any recent developmental checks

Please provide any information regarding positioning for feeding/any seating/postural equipment used

Please provide information regarding any medication including for reflux/thickeners/addititonal supplements etc

What is your primary concern about the child you are referring? *

What would you like to happen as a result of this referral? *

Please note completing this referral is not automatic acceptance of the referral by our service. The referral form will now be forwarded to the Speech & Language Therapy Team for consideration and you will be notified of the outcome

Children's Speech and Language - Feeding - NORTH ONLY