Step 1 of 6 16% Your Name* First Last Your Email* Your Phone Referee DetailsName of School/Nursery* School/Nursery: Admission Date* DD slash MM slash YYYY Date of referral to SaLT* DD slash MM slash YYYY Name of Referral Agent* Email Address of Referral Agent* Client DetailsName* D.O.B* DD slash MM slash YYYY Male or Female* Male Female Street address* Town/City Region Postal code P.O. Box Country First language Name of person with parental responsibility* Same address as above?*YesNoStreet address Town/City Region Postal code P.O. Box Country Telephone Telephone (Other) Email* Names of family membersMedical DiagnosisDate of Diagnosis and Diagnosing AgencyFurther Details: e.g. medication, special requirements Professionals InvolvedSpeech and Language Therapist Name Speech and Language Therapist Telephone Educational Psychologist Name Educational Psychologist Telephone Community Paediatrician Name Community Paediatrician Telephone Social Worker Name Social Worker Telephone Specialist Advisory Teacher Name Specialist Advisory Teacher Telephone GP Name GP Telephone Other (Name & Role) Other (Telephone) Sensory ImpairmentLast Hearing Test Hearing Test Outcome Do you think the child may have difficulty hearing?NoYesHas the child been referred for a hearing test?NoYesHave they got Visual Difficulties Summary of speech, language and communication informationPlease complete the boxes below to summarise your concerns and reasons for this referral and complete the checklist (if provided).Attention and listeningUnderstanding spoken languageIncluding following instructions. Using spoken languageIncluding putting words together, talking in sentences, telling stories. Speech sound developmentie. list of sounds that are difficult to say; general intelligibility; specific tricky sounds Social skillsInteracting with others) e.g. do they seek others to join in their play/is there a lack of interest in playing with others? Relevant DoucmentsPupil Summary Report / ProfileAvailable from Referral AgentAvailable from SchoolAvailable from ParentUnavailableNonePlease indicate how we can obtain a copy EHCP / Individual Education Plan / Statement of SENAvailable from Referral AgentAvailable from SchoolAvailable from ParentUnavailableNonePlease indicate how we can obtain a copy SignatureSignature 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. Signature* Occupation / Parent or Guardian* Signed Date* DD slash MM slash YYYY 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. Newsletter Please sign me up for the Happy Talk newsletter.