Referral Form

Please fill out Happy Talk’s referral form below. This is required from whoever is making the referral to our service in order for us to see children for specialist assessment and therapy. Please ensure that you read our Privacy Policy before submitting any personal data. If we receive an individual’s personal data from a source other than that individual or the person with parental responsibility, the required consent process will direct clients or the person with parental responsibility to our privacy information. Consent should be completed without undue delay and at least within one month.

Please note, before we can see children for specialist assessment and therapy Happy Talk Ltd also requires consent from the person with parental responsibility.

Step 1 of 6

Your Name*
First Last
Your Email*
Your Phone
Referee Details
Name of School/Nursery*
School/Nursery: Admission Date
DD slash MM slash YYYY
Date of referral to Speech & Language Therapy*
DD slash MM slash YYYY
Name of person making this referral*
Email address of person making this referral*

Referral Form

Step 1 of 6

Referee Details

Client Details

Professionals Involved

Sensory Impairment

Summary of speech, language and communication information

Relevant Doucments

Signature