R EQUEST FOR HELP FROM THE CHILDREN’S SPEECH &

r equest for help from the children’s speech & language service child’s details name of child: date of birth: sex: m/f

R EQUEST FOR HELP FROM THE
CHILDREN’S SPEECH & LANGUAGE SERVICE
CHILD’S DETAILS
Name of Child:
Date of Birth:
Sex: M/F
Address:
Postcode:
NHS Number:
Hospital Number:
Ethnicity:
Religion:
Home Telephone Number:
Home Language:
Mobile Telephone Number:
Please tick this box if you do not wish to be contacted via SMS i.e.
appointment reminder
Interpreter Required at Speech & Language Appointments: Yes/No
Language Required:
Email Address:
Please tick this box if you do not wish to be contacted via email
Parent/Carer’s Full Name:
Which speech & language therapist have you discussed this request for
help with?
Details of your local contact can be found on the website, or call
01752 434844:
https://www.livewellsouthwest.co.uk/services/childrens-speech-and-language
OTHER PROFESSIONALS INVOLVED
Agency
Name (Include Setting)
Contact Tel
GP
Health Visitor
Consultant
Educational Psychologist
CAMHS
Early Years (Please Circle Sessions)
M/T/W/T/F am/pm
School or Intended School
Teacher/TA/Keyworker
SENCO
Plymouth Early Years Inclusion Service (Gateway/Early Help)
Social Worker
Other
AREAS OF CONCERN
Please comment on areas of concern only
Hearing: Please Give Details
Is there a cause for concern in relation to hearing for speech? *Y/N
*If Yes, we require Audiology results BEFORE making a referral to our
Service and a copy of the report must be enclosed
Feeding/Swallowing: Please Give Details
Who has raised this concern?
Please comment on your concerns in any of the following areas:
listening and attention, play, ability to understand, development of
first words, joining words together, speech clarity, stammering or
social interaction.
Please comment on how this child’s speech, language or communication
needs affect them in their daily lives.
Please comment on any other concerns regarding this child’s
development or learning. Please include information on learning levels
and any IEPs in place.
Please comment on what support you have already put in place for this
child and how this has helped.
What is/are your desired outcome/s for this child/young person?
Please comment on how the speech & language service can support in
meeting the desired outcomes.
Please comment on the parent’s view regarding this child’s speech,
language and communication needs and what support they would like
(unless parent is filling out this form).
Please comment on the child/young person’s view regarding their
speech, language and communication (if applicable)?
Has this child had Speech & Language Therapy previously? *Y/N
*If Yes, please provide information e.g. NHS, School, Private
Please comment on how you have carried out the recommendations
outlined in the previous speech & language therapy report and what has
changed.
What referrals have been made to other support/health services and
what action have they taken?
Does the child have? Please delete as appropriate and include evidence
Formal diagnosis of Autistic Spectrum Condition Y/N
Educational Health Care Plan Y/N
Medical Diagnosis (please specify) Y/N
Special Needs or Learning Disabilities Y/N
Hearing Impairment Y/N
TAM in place Y/N
MASP in place Y/N
Please enclose a copy of relevant Reports e.g. Paediatrician,
Summative Assessment, ASQ, Developmental Profiles, Individual
Education Plans and National Curriculum Levels. It will help us to
process the referral if we have up to date information.
STATEMENT FROM PERSON REQUESTING HELP - I confirm:
*
I have read the Speech & Language Guidelines and understand the
request will be rejected if not met
*
That there will be a room available at the child’s setting for the
Speech & Language Service Representative to carry out therapy
appointments
*
There will be a named adult who will support the child’s
communication and attend sessions as appropriate
*
All staff at the child’s setting will carry out the advice given
Print Name: Date
Signature: Designation:
Address: Contact Number:
PARENTAL CONSENT – I confirm:
*
I have parental responsibility and I give consent for this request
for help from the Children’s Speech & Language Service
*
I understand that this may involve assessment, advice, reports and
liaison with other professionals, school or nursery as appropriate
to help my child
*
I am aware that I can discuss any element of the Service with the
Speech & Language Service representative at any time
*
I also give consent to observation and treatment from health
professional students whilst under the supervision of the Speech &
Language representative
*
I agree to attend an initial assessment appointment and further
appointments if necessary and to carry out the advice given by the
Speech & Language Service representative
*
There will be a named adult who will support the child’s
communication and attend sessions as appropriate
Print Name: Date:
Signature: Relationship to child:
Please read the above statement before signing this form.
An acknowledgement of this request will be sent to you within 2 weeks
of receipt.
Please return to: Children’s Speech & Language Service
Four Greens Community Trust, Whitleigh Green,
Plymouth. PL5 4DD
Telephone: 01752 434844
This form will be returned if all sections are not completed and the
relevant reports are not attached or we may contact you by phone to
request further information
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