Child's Details

Please note - 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

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

Consent

We are seeking consent for:

Information sharing as necessary
Referral to SLT
Inclusion in the KSL Pilot/use of SHARE App
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.

Upload Plan/Map Upload file

Has the child previously been referred to SLT? *

Yes

Please provide details of the previous referral *

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 Speech sounds Social skills and interaction

Use of language Stammering 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

KSL School Pilot - Nursery/Reception