Child and Family InformationWhat is your child's name?(Required) First Last Child's Date of Birth(Required)DayDay12345678910111213141516171819202122232425262728293031MonthMonth123456789101112YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Your name?(Required) First Last Your phone numberYour email(Required) ConsentPlease read and answer the following questions. Without consent to treatment we are not able to see your child. I consent to the Speech and Language Therapy service treating my child. I understand this may involve them consulting school staff and other professionals, observing, talking to, testing and working with my child and attending meetings about my child.(Required) Yes No I consent to the Speech and Language Therapy service accessing and sharing information with other professionals and organisations that may care for my child.(Required) Yes No Do you consent to reports and information about your child being shared by secure email with yourself and other people involved with your child?(Required) Yes No Information about your childPlease answer the questions below in as much detail as possible, with examples, to support our understanding of your child's needs and strengths and your current concerns.Is there anything in your child's medical and/or developmental history we should be aware of?(Required)Is your child being seen by any other professionals or on a waiting list to be seen?(Required)What are the current concerns about your child's speech, language and communication skills? Please give examples if you can.(Required)For example, are their concerns around their speech sounds, vocabulary, length of their sentences, being able to follow instructions, being able to communicate with others?Thinking about your last answer to question 16, what is the main concern?(Required)SummaryWould you like the Therapist allocated to your child to call you before the visit to school? The therapist will try to contact you via email/phone and leave a message if possible. If we cannot speak to you we will continue with the booked visit (if you have consented to treatment above).(Required) Yes No Your child will be allocated to a therapist when they reach the top of the waiting list. The therapist will then contact the school to arrange to go and see your child, the school should let you know when this will be. You are welcome to join the appointments, please contact the therapist or school to confirm you will attend. The therapist will contact you after the appointment to feedback the outcome and next steps. If you have any queries please email us at SLTMainstream@ghc.nhs.uk providing your name, the name of your child, and your telephone number or call the team on 0300 421 8937. Our hours are Monday – Friday 8.30am-4pm. Please leave a message on our answer machine and a member of our team will get back to you. CAPTCHA