"*" indicates required fields Child's Personal DetailsName * REQUIRED First Last Parent(s)/Carer(s) Names * REQUIREDName of person with parental responsibility * REQUIREDChild's NHS Number * REQUIREDYou can look up your child's NHS number here: www.nhs.uk/nhs-services/online-services/find-nhs-numberMain Language * REQUIREDSex * REQUIREDPlease select from the listFemaleMaleDOB * REQUIREDDayDay12345678910111213141516171819202122232425262728293031MonthMonth123456789101112YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Address * REQUIRED Address Line 1 Address Line 2 Town Postcode 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 discloseIs an interpreter needed? * REQUIREDPlease select from the listYesNoIs there anyone who regularly interprets for the family? * REQUIREDPlease give details.Parent/Carer Contact DetailsMobile Phone * REQUIREDHome Phone * REQUIREDWork Phone * REQUIREDEmail * REQUIRED Additional InformationSchool * REQUIREDGP * REQUIREDYear Group * REQUIREDHealth Visitor * REQUIREDConsentHave parents consented to this referral? * REQUIRED Consent obtained Referrer DetailsFull name of referrer * REQUIREDJob Title * REQUIREDContact Number * REQUIREDEmail * REQUIRED Is there social care involvement * REQUIRED Yes No Name of Social worker * REQUIRED First Last Email of Social worker * REQUIRED Background InformationAny other professionals involved or referrals made? * REQUIREDAs appointments may involve a home visit, is there any other information we need to know? * REQUIRED1. Is the child coughing during or immediately after feeds or meals? * REQUIRED Yes No 2. Does the child's breathing change during eating or drinking? * REQUIRED Yes No 3. Does the child have an unexplained history of chest infections? * REQUIRED Yes No 4. Has there been unexpected weight loss? * REQUIRED Yes No 5. Have feeding/eating skills recently deteriorated? * REQUIRED Yes No If you are unsure if your child meets any of these criteria please telephone to discuss with a member of the Feeding Team.Feeding History * REQUIREDPlease include all details you feel are relevant.General Development * REQUIREDPlease give details.Name of Doctor/Consultant in charge of the child's care * REQUIREDAdvice already given * REQUIREDPlease also state when this was given.Progress made since advice given * REQUIREDParent / 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. * REQUIRED Parent / carer understands Parent / 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. * REQUIRED Parent / carer understands CAPTCHA