Consent

Does the service user consent to the request for this service to be made? *

Yes

If the patient does not consent to this referral or have a best decison made, we will be unable to process this and the referral will be rejected

Does the service user have the capacity to consent to their referral? *

Yes

If no, has an MCA and Best Decision been made and documented in the service users notes *

Yes

Does the patient consent to share information? *

Yes

Do they consent to be contacted by phone, text or e-mail? *

Yes

Patient Details

Patients title *

Patient name *

Patient preferred name

NHS number *

Date of birth *

Gender *

Address *

Patients contact telephone number *

Patients contact email

Ethnicity *

Are there any relevant safeguarding concerns or issues? *

Yes

If yes, please give details *

Are there any risks associated with visiting or providing support for this person? *

Yes

If yes, please give details *

GP surgery and address *

GP Telephone number

What is the patients main spoken language? *

Is an interpreter needed? *

Yes

If yes, what language? *

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

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

Is the patient a Care Home Resident *

Yes

Is the patient a permanent resident at the Care Home *

Yes

If no, what type of bed is the patient in? ( eg: respite, short stay, D2A) *

Referrer details

Referrer name *

Telephone number *

E-mail address *

Referrers relationship to patient (e.g. consultant, therapist) *

Referred from (including hospital ward and ward contact details) *

Referral Details

Before we begin, this is a referral for Therapy only

If there is a need for Social Care, please ensure you make a separate referral to Adult Social Care.

Please tick below to confirm you understand

Tick here to confirm you have understood

Consultant and contact details (if known)

Reason for referral *

Diagnosis *

Identified Goals *

Past Medical History (Please include any eating, drinking or swallowing information) *

Does the patient have access to technology to support video consultations (e.g. phone or tablet with a camera)? *

Yes

Does a member of the patient’s family or a staff member have access to technology to support with video consultations? *

Yes

If this is not the patient, please provide the name and relationship to patient *

If the patient has access to technology to support a video consultation (either themselves or via a family/staff member), do they consent to a video consultation? *

Yes

Is the patient end of life or on the palliative care pathway? *

Yes

Please specify current presentation/status *

Does the patient have a rapidly progressing condition? *

Yes

Please give details *

Are there any concerns regarding the patient’s cognition (e.g. ability to process information, memory, attention) *

Yes

Has the patient seen a specialist for support regarding their cognition (e.g. memory clinic, Occupational Therapy)? *

Yes

Please provide more information *

Please select which services you are referring to: *

Swallowing

Communication

Swallowing Details

Please Note: If the patient only has weight loss with no associated swallow symptoms, our input is not required. Please refer or ask GP to refer to the Dietetic service.

Does the patient have difficulty swallowing tablets? *

Yes

If the patient has difficulty swallowing tablets only, and there are no concerns with their ability to eat or drink, our input is not required. Please liaise with the GP or Pharmacist regarding alternative medication formats.

Please tick all that apply *

Coughing on fluids Choking on fluids Choking/coughing on saliva Holding food or fluids in the mouth Very slow and effortful swallow, or no swallow Difficulty chewing or taking a long time to chew (If this is due to lack of dentition and there are no associted swallowing difficulties, our input is not required - please arrange a dental review.)

Coughing on food Choking on foods Gurgly, 'wet' voice or breathing Spitting food or lumps out when eating Pocketing of food in cheeks, under the tongue or at the back of the mouth

How often do the above difficulties occur e.g. every day, 2-3 times a week, weekly, rarely? Please provide details *

Does the patient have a chest infection? *

Yes

Has the patient had a chest infection in the last 3 months? *

Yes

How many chest infections has the patient had in the last year? *

Are the swallowing difficulties longstanding? *

Yes

Current diet regime *

Current fluid regime *

If other please specify

Is the patient declining or reluctant to have the recommendations previously given by Speech Therapy? *

Yes

Do you have any concerns regarding their ability to make decisions regarding their eating and/or drinking (e.g. concerns about their mental capacity) *

Does the patient need assistance with eating, drinking or mouthcare? *

Yes

Please give details. *

Swallow diary Upload file

Any additional information

Any additional attachments Upload file

Communication Details

Difficulties understanding language? *

Difficulties reading *

Difficulties finding the right words? *

Difficulties writing? *

Slurred speech? *

Stammering? *

Is the patient's communication difficulty significantly impacting on their mental health and wellbeing? *

Yes

If yes, please give details *

Is the patient's communication difficulty causing a significant barrier e.g. employment, study, living independently? *

Yes

If yes, please give details *

Has the patient seen a Speech and Language Therapist previously (including different settings e.g. hospital, hospice)? *

Yes

If yes, please give details *

Is there a high level of patient or carer distress/frustration? *

Yes

If yes, please give details *

Care Home Speech and Language support