Adult Speech and Language Therapy Services referral form
Please note that a referral does not guarantee you will be seen. All in-person appointments are held in our clinic.
As a student-led teaching clinic we will consider your referral and decide whether our service best suits your needs. This could mean we may not accept your referral. If your referral is declined, we will advise you of the reasons.
For those clients needing ongoing support, we will regularly review the frequency and appropriateness of our service and will communicate at regular intervals what to expect. At these intervals we will talk about how long we expect to keep working with you, if a referral to other services is relevant and what will happen if we are discharging you. This is to ensure that we are providing an optimal service to you and new people being referred to our clinics and to help with waiting list management.
Your Personal Data:
The organisation responsible for protection of your personal information is the University of Reading (the Data Controller). Queries regarding data protection and your rights should be directed to the University Data Protection Officer at imps@reading.ac.uk, or in writing to: University of Reading, Information Management & Policy Services, Whiteknights House, Pepper Lane, Whiteknights, Reading , RG6 6UR, UK. Some of the information we collect about you may be anonymised and used for audit statistical research purposes. This is to help us monitor equality and diversity and enhance access to our clinic by families in our local communities. Your personal data will not be shared with anyone outside the University of Reading unless we have your prior consent or if required by law. Your personal information will be retained securely in line with our records retention schedules. You have certain rights under data protection laws. You can find out more about your rights on the website of the Information Commissioners Office (ICO) at www.ico.org.uk (copy in to a new browser to open)
Please complete the form below to refer yourself or to refer on someone else’s behalf
The referral form will enable us to plan and make sure that we can help in the most appropriate way.
*PLEASE NOTE if you are making a referral about an acquired voice disorder, you will need to have had an assessment/consultation with an ENT consultant who recommends speech and language therapy, and have received their report, prior to being seen by the SLT. *
* These sections are required*
Consent to referral
Please give consent to all sections (if you are referring someone else, please consent to indicate they are aware). Please note that we may also ask for consent at clinic appointments.
I give permission for my speech and language therapy sessions to be recorded for the purpose(s) identified below:
- To contribute to my own assessment and therapy programme
- To contribute to the professional training of student speech and language therapists at the University of Reading in lectures or seminars
- To contribute to the education/training of healthcare and educational professionals
*
Yes I give consent
I understand that:
- Any written teaching materials relating to the recording will be fully anonymised
- The recording will be kept stored on a secure server that can only be accessed by SLT placement students whilst on placement and by the clinic SLTs
- At no point will the recording be made available to the general public
- At no point will the recording be put on the internet or be accessible by the internet
*
Yes I give consent
Consent for speech and language therapy student involvement
- I understand that by attending the University of Reading Independent Adult Clinic I am agreeing to the involvement and participation of speech and language therapy students. I understand that the students are working under the supervision of HCPC registered speech and language therapists
*
Yes I give consent
Consent for sharing of information
- I understand that by attending the University of Reading Independent Adult Clinic I am agreeing to speech and language therapists and speech and language therapy students sharing information and reports with NHS therapists and any other professionals involved
*
Yes I give consent
Client Details
Date of Referral*
Title
Please Select A Value...
Mr
Mrs
Miss
Ms
Dr
Rev
Prof
Master
Surname*
First Name:*
Preferred name
Preferred Pronouns
Please Select A Value...
She/Her/Her
He/Him/His
They/Them/Their
Ae/Aer/Aer
Ey/Em/Eir
Fae/Faer/Faer
Per/Per/Pers
Ve/Ver/Vers
Xe/Xem/Xyr
Ze/Hir/Hir
Date of Birth*
Gender*
Male
Female
Indeterminate
Missing data (not recorded/not yet known)
NHS Number (if known)
Ethnicity*
Please Select A Value...
White - British
White - Irish
White - Any other White background
Mixed - White and Black Caribbean
Mixed - White and Black African
Mixed - White and Asian
Mixed - Any other mixed background
Asian or Asian British - Indian
Asian or Asian British - Pakistani
Asian or Asian British - Bangladeshi
Asian or Asian British - Any other Asian background
Black or Black British - Caribbean
Black or Black British - African
Black or Black British - Any other Black background
Other Ethnic Groups - Chinese
Other Ethnic Groups - Any other ethnic group
Not Stated - Not Stated
What languages are spoken by the person who is being referred?*
Client contact details
Address Line 1*
Address Line 2
Town/City*
County*
Postcode*
Please provide at least one phone number in the following fields, one you can be reached on during the day.
Mobile Number
Permission to contact by SMS*
No
Yes
Permission to leave voicemail*
No
Yes
Home Number
Permission to leave voicemail*
No
Yes
Email*
Next of kin details
Surname*
First Name*
Address (including postcode) if different from above*
Phone number (one you can be reached on during the day)*
Email address*
GP Details
GP Name /Practice Name & Address*
GP email (for office use):*
Medical History
Diagnosis
Date Of Onset
Scan / investigation results
Relevant Medical History
Reason for the referral
Please tick the box/boxes that are relevant to the referral*
Difficulties understanding language
Difficulties with expressive language
Difficulties with reading
Difficulties with writing
Voice difficulties
Dysfluency e.g., stammer
Dysarthria e.g. slurred speech
Apraxia of speech
Cognitive communication difficulties
Difficulties with eating, drinking, swallowing
Other
If other, please explain.
Please give further information for the reason(s) for the referral. Please include full details and relevant dates*
What impact are these difficulties having on the person being referred?*
What is the person being referred hoping to gain from speech and language therapy?*
Speech and language therapy/professional involvement details
Has the person being referred been or, currently, under the care of another SLT service (NHS or private)?
Yes
No
Unknown
If yes, please specify and provide their name and contact details.
Details of any other professionals or charities involved in the person’s care now (e.g., psychologist, community-based neuro rehabilitation team, Headway, Stroke association.) Please provide their name and contact details (if known) Please indicate if you/the client has been referred and is waiting for another service.
Access to speech and language therapy sessions
Can you/the client attend the clinic in person? (check box)
Yes
No
Don't Know
Do you/the client have access to a laptop/computer/tablet to attend sessions via video call *
Yes
No
Don't Know
Anything we need to know about the mobility of the person who is being referred? Let us know what you need to walk/move safely*
Anything we need to know about the hearing of the person who is being referred?*
Anything we need to know about the vision of the person who is being referred?*
Please indicate if the person being referred needs an interpreter for the initial appointment.*
Yes
No
Don't Know
If yes, please specify the language this is needed for*
Referrer's Details
Full Name*
Address Line 1*
Address Line 2
Town/City*
Post Code*
Contact telephone number*
Email address*
Please email adult-slt@reading.ac.uk with any previous SLT reports and any reports from other professionals that may be relevant.
*PLEASE REMEMBER if you are making a referral about an acquired voice disorder, you/your client will need to have had an assessment/consultation with an ENT consultant who recommends speech and language therapy, and have received their report, prior to being seen by a SLT. *
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