Referral Form

School/Nursery: Admission Date

(as appropriate)

Date of referral to SaLT

D.O.B

Male or Female
Home address
Address if different from child

Telephone Number

Order
Name and Telephone Number
Name and Phone number
Name and Phone number
Name and Phone number
Name and telephone number
Name and phone number
Name / Role and Phone number
Select if YES
Select if YES
Please complete the boxes below to summarise your concerns and reasons for this referral and complete the checklist (if provided).
Including following instructions.
Including putting words together, talking in sentences, telling stories.
ie. list of sounds that are difficult to say; general intelligibility; specific tricky sounds
Interacting with others) e.g. do they seek others to join in their play/is there a lack of interest in playing with others?
Please indicate how we can obtain a copy
Please indicate how we can obtain a copy
Signature of professional completing the case history / referral form page. By signing this referral you are confirming that you have discussed the reason for this referral with the person who has parental responsibility and gained their consent to “Happy Talk” Speech and Language Therapy seeing their child for assessment.

Signed Date

As long as we have signed consent to share information from the person with parental responsibility we will be able to discuss the status of this referral with you.