Referral & Consent Forms - Happy Talk Speech and Language Therapy

Please complete this case history to supplement the referral information provided for your child.

Case History

This field is hidden when viewing the form

Date of Entry

Child's Name(Required)

Age(Required)

Names of Parents/Carers:(Required)

Contact Email(Required)

Name and address of School / Nursery

Do you consent to Happy Talk sharing the outcome and recommendations of your child's assessment with your child's school / nursery / GP?

What are your concerns regarding your child’s speech, language, and communication?

(Attention and listening, understanding of language, spoken language, speech sounds, fluency, voice, social communication)

Is your child aware of their difficulties? How do they show this?

How is your child getting on in school/nursery? Do they receive additional support?

Is there a language other than English spoken at home?

If yes which one?

Does your child understand/speak this language?

Do you feel your child also has difficulties understanding/speaking in this language?

Which language does your child prefer to speak at home?

Has your child ever had speech and language therapy in the past?

Does your child receive support from any other professionals or have they in the past?

(e.g., Paediatrician, CAMHS, Physio, OT, Ed Psych, Specialist Teaching Service, Counselling, Social Worker etc.)

Does your child have any visual, hearing, or sensory needs?

Tell us about your child’s developmental milestones. When did they babble? First Words? Two Words together?

Did your child have any difficulties feeding? As a baby? Difficulties weaning? Now?

Does your child have any diagnosed medical conditions, or have they had any significant illnesses during childhood?

Is there anything else you would like to tell me about your child’s speech, language, or communication at home/school?