Step 1 of 4 25% Please read the information in the pink box above before you continue(Required) I have read and understand the information above You cannot continue with this form until you have read and understood the information above. If you need more help or have any questions that prevent you from ticking the box, please contact the SLT team at sltchild@ghc.nhs.ukHave you gained consent from either the parent, guardian or carer?(Required) Yes, I have gained consentDate parental consent was gained(Required) DD slash MM slash YYYY This referral cannot be accepted without the consent and date of consent of the child's parent, guardian or carer. Child's Personal DetailsChild's name(Required) First Last Child's date of birth(Required) DD slash MM slash YYYY Child's NHS numberYou can look up your child's NHS number on the Find your NHS number page.Child's address Street address Address line 2 Town / city Postal code Details of the person completing this formYour email(Required) Your name(Required) First Last Is your address the same as the child?(Required) Yes No Your address Street address Address line 2 Town / city Post code Your relationship with the child(Required) Parent Guardian Foster carer Social worker Teacher Consultant Other If other, please give more details.Name of person with parental responsibility First Last Phone number of person with parental responsibilityEmail of person with parental responsibility Does the child have a Delegation of Authority document?(Required) Yes No Please upload the Delegation of Authority or other documentation which confirms that you have legal authority or parental responsibility for the childMax. file size: 64 MB. Parent / Carer DetailsParent / carer name First Last Is the parent / carer address the same as the child's? Yes No Parent / carer address Street address Address line 2 Town / city Post code Is the parent / carer email the same as the requester? Yes No Parent / carer email Parent / carer phone number Has your child been seen by the Speech and Language Therapy Service within the last 12 months? Yes No Is this referral for the same needs or a new concern?(Required) Same needs New concern About the childSex assigned at birthPlease select oneMaleFemaleIdentifies asPlease select oneMaleFemaleNon-binaryPrefer not to sayPrefer to self describePlease describe to us how you would like to be identifiedPreferred pronounsPlease select oneHe/him/hisShe/her/hersThey/them/theirsPrefer not to sayPrefer to self describeEthnicityPlease select oneEnglishHindiPolishSpanishFrenchArabicChineseBengaliRomanianTamilSlovakOtherIf other, please specify child's ethnicityMain language used at homePlease select oneEnglishHindiPolishSpanishFrenchModern Standard ArabicMandarin ChineseBengaliRomanianTamilSlovakBSLOtherIf other, please specify child's preferred languageIs an interpreter needed for the child? Yes No Is an interpreter needed for the parent? Yes No Does this child have any accessibility needs? Yes No Please specify what accessibility needs the child requiresName of education setting / nurseryYear groupGraduated PathwayPlease select oneNot ApplicableMy PlanMy Plan PlusEHCPEarly HelpGP practiceIs there social care involvement? Yes No Social worker name First Last Social worker email Social worker phone numberWhich type of social care involvement is there? Child Protection Plan Child in Need Child in Care Does the child have any medical diagnoses?Have any of the following professionals been involved? Advisory Teaching Service Audiology CAMHS Educational Psychologist Family / Community Support Workers Health Visiting Occupational Therapist Paediatrician Physiotherapist School Nurse Social Worker Other Please give more detail on the professional involvementWhat areas of Speech and Language are you concerned about for the child?(Required) Speech clarity Understanding Language Using Language Stammering Other If other. Please describe in more detail the condition you are concerned aboutSpeech clarityHas your child had their hearing checked? Yes No When was the child's hearing checked? DD slash MM slash YYYY Have they been seen by the Ear, Nose and Throat team? Yes No Does your child have a dummy or suck their thumb? Yes No What have you tried already to support their speaking and is this helping?How does your child respond when trying to say or do something they find difficult? Easily overwhelmed by setbacks, shuts down or refuses to try again Often avoids challenges or gives up quickly, even with encouragement Shows some persistence, but gives up easily if challenged or discouraged Needs a little support but generally recovers from setbacks and keeps going Quickly bounces back after challenges. Tries again without giving up How well does your child pay attention and listen during tasks or conversations? Never – rarely focused, unable to stay on task even with help Rarely – frequently distracted, needs frequent redirection Sometimes – needs some reminders to stay on task Usually – minor distractions but returns quickly to the task Always – fully focused without reminders How well do you think your child is understood by you? Never Rarely Sometimes Usually Always How well do you think your child is understood by other family members? Never Rarely Sometimes Usually Always How well do you think your child is understood by people outside the family?For example: teachers or other children Never Rarely Sometimes Usually Always How much do their speech errors affect their confidence and friendships? Never Rarely Sometimes Usually Always How do you know their confidence and / or friendships are affected?How concerned are you about your child’s speech sounds (how clearly they speak)? Never Rarely Sometimes Usually Always Is another person / professional concerned about your child’s speech? Yes No Have you noticed which sounds are tricky for your child?Understanding languageWhat type of instructions can the child follow? They cannot follow any instructions. They can respond to their name. They can follow simple instructions with one key word or that are part of routine – eg “where’s the ball” “Go find your coat” (as you are going to the front door). They can follow longer instructions with multiple key words – eg “put the yellow ball on the chair. They can follow instructions in two parts – eg “Get your book and then line up by the door”. They can follow all instructions. Does anything help them to follow an instruction?For example: breaking the instructions down into smaller chunks or repeating the instruction to them.Does the child understand questions? They cannot understand any questions They can understand who, what or where questions They can understand how and why questions They understand all questions Does the child have difficulty remembering what they have been asked to do? Yes No How well does your child pay attention and listen during tasks or conversations? Never – rarely focused, unable to stay on task even with help Rarely – frequently distracted, needs frequent redirection Sometimes – needs some reminders to stay on task Usually – minor distractions but returns quickly to the task Always – fully focused without reminders Using languageHow does the child let you know that they want or need something?For example: pointing, show a picture, say a word, use a sentence.What statement best describes how the child communicates They do not use any words, pictures, signs or objects to get the message across They can use single words / pictures / signs / objects to get the message across They can join 2 to 3 words in short phrases to get the message across They can use 4 or more words in a sentence to get the message across but this is not grammatically correct They can join short phrases and sentences together but this is not always grammatically correct They can join short phrases and sentences together with the correct grammar They can use language to tell a story or describe what has happened If your child is using words, please tick the below statements that apply They are using nouns (naming words – people, places or things) They are using verbs (doing words – like jumping, washing) They sometimes say the wrong word (for example: watermelon instead of pineapple) They use empty words more often than you would expect (for example: thing, stuff, it, that one) They find it hard to learn and remember new words What have you tried already to support this?Please include if any strategies have been helpful.StammeringHow worried are you about your child’s stammer? Extremely worried Worried Becoming more worried Slightly worried Not worried How worried is your child about their stammer? Extremely worried Worried Becoming more worried Slightly worried Not worried Please tell us more about your child’s stammerPlease tick all that apply Does your child repeat whole words, e.g. 'my my my'? Does your child repeat sounds in words, e.g. 'c-c-can', 'mum-um-um'? Does your child stretch sounds out, e.g. 'ssssssso'? Does your child block (this looks like they are trying to say a word, but no sound comes out)? Does your child look tense in their face or body when they stammer? Does your child hold their breath or breath in unusual places when they are stammering? Does the pitch/volume of your child’s voice go up and down when he/she is stammering? Does your child move parts of their body when they are stammering to help get the words out, e.g. tapping their fingers or feet, lifting their arms etc. Does your child do any of the following?Please tick all that apply Change words when they stammers? Avoid saying certain words because they are worried about stammering? Does your child give up talking or decide not to talk because of their stammer? Does your child talk about their stammer? Please give examples of the above.Has your child ever been bullied or teased about their stammer? Yes No What happened?When did you first notice your child was stammering?Has it changed since then? Getting better Staying the same Getting worse When is talking easier for your child?When is talking harder for your child?Is there any history of stammering in your family? Yes No Don't know If yes, is that person still stammering as an adult?Please tell us about the things you are already doing to help your child when he/she is stammering.This field is hidden when viewing the formSection BreakIf you have selected more than one area of Speech and Language concern, what is your primary concern? Speech clarity Understanding Language Using Language Stammering Other Returners formAre there any changes to personal information since the last episode of care? None Address Parent / carer details School GP Other Address Street address Address line 2 Town / city Postal code Parent / carer detailsEducational setting / nursery nameSchool / educational address Street address Address line 2 Town / city Post code GP practice nameGP practice address Street address Address line 2 Town / city Post code Please give details of any changes to personal information that are relevantWhat speech and language goals have you been working on, what progress has the child made?How often have you carried out activities and strategies recommended by the Speech and Language Therapist? Daily 3-4 times a week 1-2 times a week Less than once a week It can often take time for children to learn and generalise new skills. We would recommend carrying out the recommendations consistently for at least 3 months before referring.How helpful were the activities and strategies that you have tried? Very helpful - Significant progress Moderately helpful - Some progress Slightly helpful - Limited progress Not helpful - No noticeable progress Unsure / too early to tell What support do you need from this request for help?Please upload any supporting documentsMax. file size: 64 MB. Additional InformationDo you have any other information you want to share? Please provide description of concerns if you have not already done this.Does the child’s speech or language difficulty impact them in their daily activities? Yes No Please specify how the child’s speech or language difficulties impacts themWhat is the child's view on these difficulties and how it impacts them?What is the desired outcome from this request for assistance?Please summarise the actions you have already taken to support this child/ young person's speech and language needsFor example: Extra classroom support, small group work, visual timetable. What do you feel helps the child/ what doesn’t help?Please upload any supporting documentsMax. file size: 64 MB. CAPTCHA