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 may 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 and your child 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 and paste in to a new browser)

Please complete the form below to refer your child. Please note that we only accept referrals from parents/carers.

The referral form will enable us to plan and make sure that we can help in the most appropriate way.

These sections are required*

Audio/Video Consent

I give permission for my child’s speech and language therapy sessions and parent interviews to be recorded for the purpose(s) identified below:

- To contribute to the child’s 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 education professionals

I understand that:

- Any written teaching materials related 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.

Where appropriate, I will make my child aware that the sessions are being recorded.

*

Yes I give consent

Consent for Speech and Language Therapy Student Involvement

- I understand that by attending the University of Reading Independent Paediatric 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.

Where appropriate, I will make my child aware that student speech and language therapists are involved.

*

Yes I give consent

Consent for Sharing of Information

- I understand that by attending the University of Reading Independent Paediatric Clinic I am agreeing to speech and language therapists and speech and language therapy students sharing information and reports with NHS therapists, my child’s education setting, and any other professionals involved.

Where appropriate, I will make my child aware of this.

*

Yes I give consent

Title

Child's Last Name*

Child's First Name*

Child’s preferred name

Child’s preferred pronouns

Child's Date of Birth*

Child's Gender*

Male

Female

Indeterminate

Missing data (not recorded/not yet known)

Child's NHS Number*

Ethnicity of child*

Educational setting*

Educational setting contact phone or email*

Name of SENCo or nursery key worker*

Parent(s)/carer(s) name(s) and what your child calls you e.g., ‘Mummy,’ ‘Baba’*

Child's home address (if more than one, please give details of the address where the child lives with the parent completing the referral)*

Address Line 1*

Address Line 2

Town/City*

County*

Postcode*

Parent(s)/carer(s) email address*

House phone/mobile number of parent(s)/carer(s)*

Mobile Number

Permission to contact by SMS*

No

Yes

Permission to leave voicemail*

No

Yes

Home Number

Permission to leave voicemail*

No

Yes

Who lives in your home(s) and their relationship to your child

Ethnicity of parent completing the form*

Please specify your relationship to the child you are referring e.g., father, mother, carer. If carer, please specify the parent you have completed ethnicity for*

Religion

Child’s GP name/practice name and address*

GP email (for office use)

Please give a brief summary of your concerns about your child’s language, communication and speech*

Please give a brief summary about any other areas of concern.

What effect are these difficulties having on your child and/or your family?*

What are you hoping to gain from speech and language therapy?*

Are there concerns about your child from their education setting? If these concerns differ from yours, please specify.

Is your child currently under the care of a SLT – if yes, please provide their name and contact details*

Has your child ever been seen by a SLT – if yes, please give details*

Details of any other professional involved such as a paediatrician, occupational therapist, educational psychologist. Please provide their name and contact details Please indicate if your child has been referred and is waiting for another service*

Was your child born at full term? (37 weeks+)

Yes

No

What was their birth weight?

Were there any complications surrounding the pregnancy/birth/after birth?

Has your child had their hearing tested? If yes, please specify when this was and the result*

Has your child ever had any significant health difficulties/spent time in hospital/had surgery?

At what age did your child:*

Crawl:*

Walk:*

Become dry in the daytime:*

Make playful babble (e.g., ba-ba, ga-ga etc):*

Say their first words:*

Join 2 words together (e.g., more juice, daddy gone):

Does your child have any medical diagnoses? If yes, please specify*

Describe your child’s interests, likes and any dislikes if relevant*

What languages is your child exposed to in the home?*

If you feel your child is more competent in one of these languages, please indicate which one.

Please indicate if you need an interpreter for the initial appointment*

Yes

No

If yes, please specify the language this is needed for*

Please describe any additional access needs for your child or the accompanying adult(s) e.g., wheelchair access*

How did you hear about our service?

Please email paediatric-slt@reading.ac.uk with any previous SLT reports and any reports from other professionals that may be relevant.

Please complete the captcha

Paediatric Speech and Language Therapy Services referral form

Consent

About the person you are referring

Parent(s)/carer(s) details

GP details

Reason for the referral

Speech and language therapy/professional involvement details for the child you are referring

Developmental history of the child you are referring

Access to speech and language therapy sessions