Child's Details

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

Name *

Date of Birth *

Address *

Telephone *

Parent/carer email *

Gender *

Overseas visitor? *

Yes

Ethnicity *

Please state all the languages spoken at home *

Is an interpreter needed for the parent / carer / child? *

Yes

If yes, for which 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? *

We are seeking consent for:

Information sharing as necessary
Referral to SLT
Contact by text/email/post/telephone
Consultation by telephone/video

Parents/carers consent *

Yes

Referral Details

Referrer Name *

Referrer Role *

Address *

Telephone number *

Email *

Name of school, nursery or preschool *

Year group *

Supporting evidence needs to be included to support the referral (IEP, Provision Map, ANP, MSP etc) and must include specific speech, language or communication targets and have been reviewed at least twice in school. We will not accept referrals that do not meet this criteria unless the referral is specifically for a concern about stammering or a voice problem. The Quality First Teaching (QFT) guidelines (SEND Code of Practice 2014 Kirklees Document) are used when we process our referrals. The QFT incorporates many of the strategies and advice that we recommend for supporting a child initially with SLCN and can be implemented without the need to make a referral to our service.

Please ensure any documentation uploaded does not contain name or details of other children or young people.

Does the child have an Education Health and Care Plan (EHCP) / My Support Plan (MSP) / Individual Education Plan (IEP) or Provision Map? *

Education Health and Care Plan (EHCP) Individual Education Plan (IEP)

My Support Plan (MSP) Provision Map

Please attach this Upload file

Has the child previously been referred to SLT? *

Yes

Details

Any known diagnosed medical conditions? *

Is the child known to a Paediatrician? *

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

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

I have read the information on Speech and Language Development and Guidelines for referral

Reason for Referral

(Please provide as much detail about the child’s areas of difficulty as possible to help us process this referral accurately)

What is the main reason you are making this referral? *

Understanding of language *

Use of language *

Speech sounds *

Stammering

Social skills and interaction

Voice quality (croaky / hoarse)

What is the impact of these difficulties? *

Additional information

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 - Communication - NORTH ONLY