"*" indicates required fields Step 1 of 2 50% Parent / carer understands that a Specialist Speech and Language Therapist will review this referral within 2 weeks of it being submitted and will be in contact within 6 weeks to make a plan.* The Parent / carer understandsParent / carer understands that if they are concerned about their child’s health or safety in relation to a feeding / swallowing issue then they should visit either their GP or in emergency cases go to Accident and Emergency at one of the local hospitals.* The Parent / carer understandsHave you gained parental consent for this request for assistance?* Yes No Date parental consent was gained* Day Month Year Parental consent to contact and share information with involved professionals* Yes No Unfortunately, we cannot accept referrals without the consent of the child's parent / guardian / carer. Child's Personal DetailsChild's name* First Last Child's date of birth*DayDay12345678910111213141516171819202122232425262728293031MonthMonth123456789101112YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Child's address* Address Line 1 Address Line 2 Town Postcode Child's NHS number*You can look up the child's NHS number at: Find your NHS numberGender at birth*Please select from the listFemaleMaleDoes the child Identify as another gender?*Please select from the listNoMaleFemaleOtherPrefer not to sayPlease tell us which gender the child identifies asWhat pronoun would the child prefer?*Please select from the listHe / himShe / herThey / themOtherEthnicity*Please select from the listWhite - British (to include Northern Ireland, Scotland and Wales)White - IrishWhite - EuropeanWhite - OtherBlack or Black British - CaribbeanBlack or Black British - AfricanBlack - OtherAsian or Asian British - IndianAsian or Asian British - PakistaniAsian or Asian British - BangladeshiAsian - ChineseAsian - OtherMixed - White and Black CaribbeanMixed - White and Black AfricanMixed - White and AsianMixed - OtherEthnic identity not knownDo not wish to discloseMain language spoken at home*Is an interpreter needed for the child or parent?* Yes No If yes, please give more details if different from main languageDoes the child have any accessibility needs?* Yes No Please detail the accessibility needs the child requiresParent / Carer Contact DetailsName of the child's main carer* First Last Main carer's relationship to the childPlease select from the listParentCarerOtherIf other, please give more details below.Name of person with parental responsibility* First Last Parent / carer phone number*Parent / carer email* Additional InformationName of nursery / school*Year groupName of GP practice*Is there any social care involvement?* Yes No Professional InvolvementHave any professionals been involved?* Yes No Have any of the following professionals been involved?* Advisory Teaching Service Audiology Community Children’s Nursing Complex Nursing Care CYPS (previously CAMHS) Dietitian Educational Psychologist ENT Family / Community Support Workers Gastroenterology Health Visiting Occupational Therapist Paediatrician Physiotherapist School Nurse Social Worker Specialist Hospital e.g. Bristol, Birmingham, London Other If other, please give more detailsIf possible, please supply the name of the professionals and describe how supported.Background InformationMedical History / Medical Diagnosis / Current investigations / Medications*Has the child had any chest infections requiring antibiotics in the last 18 months?* Yes No Please give more details of the illness and an approximate date.Any worries about weight loss?* Yes No Please give more detail about your weight loss worries?Has the child had Speech and Language Therapy support for eating, drinking or swallowing in the past?* Yes No Does the child eat and drink in specialist seating?* Yes No Please describe more about the seatingWhat are your worries the child’s eating, drinking and swallowing?*How long has this been a concern?Please describe what the child eats over the course of the day*Include the time of eating, range of different foods eaten, amounts, textures i.e. puree/ small piecesPlease describe what the child drinks over the course of the day?*E.g. amounts, frequency, timesWhat does the child drink out of?*E.g. bottle – make of bottle and teat size / type, beaker brand, open cupPlease can you list any food or drinks the child finds difficult to manage?*What do you do to help the child eat and drink at the moment?*E.g. chopping, puree, little and often during the dayIs there anything else you would like to tell us about the child’s eating and drinking?Details of person completing this formName of referrer* First Last Job title or relationship to childparent / carer / guardianHealth professionalGPNursery / schoolOtherIf health professional or other, please give job titleReferrer's contact number*Referrer's email* Supporting documentationPlease upload supporting documentation in PDF format only e.g any relevant clinic letters or reports.Max. file size: 64 MB. If you are unsure if your child meets any of these criteria please telephone to discuss with a member of the Feeding Team.CAPTCHA