"*" indicates required fields Child's Personal DetailsName * REQUIRED First Last Parent(s)/Carer(s) Names * REQUIREDDate of Birth * REQUIREDDayDay12345678910111213141516171819202122232425262728293031MonthMonth123456789101112YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Child's NHS NumberYou can look up your child's NHS number here: www.nhs.uk/nhs-services/online-services/find-nhs-numberSex assigned at birth * REQUIREDPlease select from the listFemaleMaleIdentifies as: * REQUIREDPlease select from the listMaleFemaleNon-binaryPrefer not to sayPrefer to self-describeIf you answered 'Prefer to self-describe' please specify: * REQUIREDPreferred pronouns: * REQUIREDPlease select from the listHe/him/isShe/her/hersThey/them/theirsPrefer to self-describeIf you answered 'Prefer to self-describe' please specify:Ethnicity * REQUIREDPlease 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 discloseNHS NumberMain Language * REQUIREDIs an interpreter needed? * REQUIREDPlease select from the listYesNoDoes this child have any accessibility needs? * REQUIRED Yes No If yes, please describe in more detail. * REQUIREDAddress * REQUIRED Address Line 1 Address Line 2 Town Postcode Parent/Carer Contact DetailsName of child's main carer * REQUIREDRelationship with child---please select one---ParentGuardianFoster carerSocial workerTeacherConsultantOtherPlease 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.If you are unable to upload the required documentation, please mail it to SLTchild@ghc.nhs.ukName of person with parental responsibility * REQUIREDMobile Phone * REQUIREDHome PhoneWork PhoneEmail * REQUIRED ConsentHave you gained parental consent for this request for assistance?Consent obtained from * REQUIREDParentGuardianCarerPlease note that referrals cannot be accepted without the consent of the child's parent/guardian/carer.Date parental consent gained * REQUIRED DD slash MM slash YYYY Parental consent to contact and share information with involved professionals? * REQUIRED Yes No Additional InformationEducation setting * REQUIREDYear GroupGP * REQUIREDIs there social care involvement? * REQUIRED Yes No Which type of social care involvement is there? * REQUIRED Child Protection Plan Child in Need Child in Care Graduated PathwayNot ApplicableMy PlanMy Plan PlusStatement of SEN or EHCPIf applicable.Medical DiagnosisRequest Type * REQUIRED New request / At least 6 months post last SLT contact Request for further episode of care for child already known to service Professionals InvolvedHave any of the following professionals been involved? Advisory Teaching Service Audiology CYPS (previously CAMHS) Educational Psychologist Family / Community Support Workers Health Visiting Occupational Therapist Other Paediatrician Physiotherapist School Nurse Social Worker If any professional involvement has been identified in box above please supply name and type of support in box belowConcernsParent/carer/requester reason for request for assistance * REQUIREDChild/young person's view * REQUIREDWhat is the desired outcome from this request for assistance? * REQUIREDPlease summarise the actions you have already taken to support this child/young person's speech and language needs. * REQUIREDE.g. Extra classroom support, small group work, visual timetable. Requester DetailsFull name of requester * REQUIREDJob Title * REQUIREDRequester organisation/profession or enter parent/carer/guardian * REQUIREDContact Number * REQUIREDRequester email * REQUIRED Supporting documentationMax. file size: 64 MB.Please upload supporting documentation in PDF format only. UntitledFirst ChoiceSecond ChoiceThird ChoiceUntitledUntitledUntitledUntitledFirst ChoiceSecond ChoiceThird ChoiceUntitledUntitledCAPTCHA