SCHOOL REFERRAL TO SPEECH & LANGUAGE THERAPY
WORCESTERSHIRE CHILDREN’S HEALTH SERVICES SPEECH & LANGUAGE THERAPY SERVICE CHECKLIST In order for the referral to be processed, it is essential to provide the following information: Please confirm the following by ticking the box:
Completed ‘Speech & Language Therapy Referral Form for School Age Children’
Completed ‘Parent Consent Form’
Copies of reports from other agencies
Copy of Language Link assessment (if carried out in YR)
Copies of the last two IEPs
Please return form to: Catshill Clinic, The Dock, Bromsgrove, B61 0NJ Tel: 01527 488326 (Bromsgrove & Redditch) Franche Clinic, Marlpool Place, Kidderminster, DY11 5BB Tel: 01562 752749 (Wyre Forest) Isaac Maddox House, Shrub Hill, Worcester, WR4 9RW Tel: 01905 681592 (South Worcestershire)
Bromsgrove & Redditch: 01527 488326
Wyre Forest: 01562 752749
www.hacw.nhs.uk
South Worcestershire: 01905 681592
SCHOOL REFERRAL TO SPEECH & LANGUAGE THERAPY Child’s personal details: Name:
DoB:
Address:
Telephone No:
Parents/Carer’s Name:
GP:
School: Year Group:
Surgery:
Class Teacher: SENCo:
Have parents consented to this referral?
Yes
No
Please attach completed and signed parent consent form. Please note we CANNOT accept referrals without parental consent.
Background Information: Reason for Referral:
Relevant medical history: Relevant family history: Looked After Child: Dates and Results of hearing tests if known:
Passed
Stage on SEN Register:
School Action +:
Statement:
Language Link Results: If carried out in YR National Curriculum Level:
Total Score:
Red / Blue / White (please circle) Science:
English:
Maths:
Failed
Has child been seen by Speech & Language Therapy before?
Yes
No
Have you discussed this referral with a Speech & Language Therapist. Please give details:
Yes
No
Referred by: Designation: Bromsgrove & Redditch: 01527 488326
Date: Wyre Forest: 01562 752749
www.hacw.nhs.uk
South Worcestershire: 01905 681592
Name:
INVOLVEMENT OF OTHER AGENCIES
Have any of the following professionals been involved?
Please tick all that apply
Report attached
Learning & Behaviour Integrated Specialist Support Services Educational Psychology Clinical Psychology Service Occupational Therapy CASBAT CAMHS Other:
LEVEL OF ANXIETY OR CONCERN
School Staff
None
Mild
Moderate
Severe
Parents
None
Mild
Moderate
Severe
Child
None
Mild
Moderate
Severe
Bromsgrove & Redditch: 01527 488326
Wyre Forest: 01562 752749
www.hacw.nhs.uk
South Worcestershire: 01905 681592
Name:
ACTION AT SCHOOL ACTION Please give details: 1. Identification of Speech, Language or Communication Needs:
2. Strategies and Outcomes: i.e. strategies and resources used at School Action and identified on the IEP or Individual Provision Map Strategies & Resources in Use
Outcome
Whole Class (Wave 1) e.g. teaching good listening skills
Small Group Intervention (Wave 2) e.g. Time to Talk
Bromsgrove & Redditch: 01527 488326
Wyre Forest: 01562 752749
www.hacw.nhs.uk
South Worcestershire: 01905 681592
Name:
SPEECH, LANGUAGE AND COMMUNICATION SKILLS Instructions for completing this form: Each of these sections asks you to compare the child’s skills with those of others in the class. At the end of each section there is a space for your comments. Please add any extra information which you think may be useful.
1. Attention & Listening: How well can the child… Skill:
Less able than others in class:
Similar ability to others in class:
More able than others in class:
Listen to whole class discussions? Give eye contact as appropriate? Stay on task without adult support? Behave appropriately?
Comments:
(Please tick as appropriate)
2. Receptive Language Skills (understanding of language): How well can the child… Skill:
Less able than others in class:
Similar ability to others in class:
More able than others in class:
Remember long instructions? Understand verbal instructions? Follow stories or explanations? Understand abstract language (jokes/idioms /metaphors etc)? Ask for clarification if s/he has not understood?
Comments:
(Please tick as appropriate) Bromsgrove & Redditch: 01527 488326
Wyre Forest: 01562 752749
www.hacw.nhs.uk
South Worcestershire: 01905 681592
Name:
3. Expressive Language Skills (use of language): How well can the child… Skill:
Less able than others in class:
Similar ability to others in class:
More able than others in class:
Take part in class discussions? Use appropriate word order in sentences? Use word endings (eg –ed, ing) & include small grammatical words (eg. is, a,) Use vocabulary appropriately? Relate an event/story with appropriate order and detail? Make predictions and give explanations?
Comments:
(Please tick as appropriate)
4. Social Skills/Use of Language: How well can the child… Skill:
Less able than others in class:
Similar ability to others in class:
More able than others in class:
Start conversations with adults? Start conversations with children? Use eye contact & facial expression appropriately? Change their communication style according to the situation? Play cooperatively with other children? Make friends?
Comments:
(Please tick as appropriate) Does the child often change the topic unexpectedly? Does the child have a favourite topic that they talk about for an unusual amount of time?
YES
NO
YES
NO
Bromsgrove & Redditch: 01527 488326
Wyre Forest: 01562 752749
www.hacw.nhs.uk
South Worcestershire: 01905 681592
Name:
5. Speech sounds/Pronunciation: Can the child be understood by… Familiar adults?
Yes
No
Unfamiliar adults?
Yes
No
Other children?
Yes
No
Comments:
What words or sounds (if any) are difficult for the child to pronounce?
Is the child’s speech usually fluent? i.e. does child repeat sounds, words several times? Does the child have a hoarse voice/voice loss?
Yes
No
Yes
No
6. Other Skills: Please indicate how the child’s skills in the following areas compare with other children in the class: Skill:
Less able than others in class:
Similar ability to others in class:
More able than others in class:
Reading: Spelling: Maths: Drawing/painting: P.E.: Practical activities: (e.g. technology/experiments)
Comments:
(Please tick as appropriate) Additional Comments:
Thank you for completing this form. Please return it to your local Speech & Language Team Bromsgrove & Redditch: 01527 488326
Wyre Forest: 01562 752749
www.hacw.nhs.uk
South Worcestershire: 01905 681592
PARENT CONSENT FORM
Worcestershire Children’s Health Services
-
Speech and Language Therapy Service
Child’s name …………………………………………………………………………................................... Date of birth ………………………………Nursery/School:…………………………................................
Please tick box to show whether you do or do not give consent to the following: Yes
No
For my child to be referred to the speech and language therapy service
For any relevant information about my child to be shared between the speech and language therapist and health, education, and social services professionals as appropriate. This will include sending copies of written reports.
For the therapist to visit my child’s playgroup/nursery/school to carry out assessments and offer advice to the staff.
For student speech and language therapists to observe or participate in speech and language therapy with my child. This will always be under the supervision of the speech and language therapist.
Audio, video or photographic records may be made as part of my child’s speech and language therapy.
To be signed by a person who holds ‘parental responsibility’ * for the child named above. Signed…………………………………………………………………….................................... Print name:
…………………………………………………………......................................
Relationship to child: ………………………………………………. Date: ……………............ * Under the Children’s Act 1989 certain people hold ‘parental responsibility for a child. This may include the child’s mother; the father if the parents are married at the time; the father if he has acquired responsibility by a court order or by a document in a proper legal form agreed by the mother; adoptive parents; others who have acquired parental responsibility through legal systems e.g. residence order, parental responsibility order. Bromsgrove & Redditch: 01527 488326
Wyre Forest: 01562 752749
www.hacw.nhs.uk
South Worcestershire: 01905 681592
ETHNIC GROUP
What ethnic group does your child belong to? - please tick one of the boxes below. You do not have to answer this question, but the information is important. It is collected in order to help the NHS understand the needs of patients and service users from different groups, and so provide better and more appropriate services. The information you provide will be treated as part of your confidential NHS case notes, and will not be shared with any other person or organisation. The NHS has strict standards regarding data protection, and the information will be carefully safeguarded. Please tick one box to show your child’s ethnic group:
White - British White - Irish White – any other white background Mixed – White & Black Caribbean Mixed – White & Black African Asian or Asian British – Indian Asian or Asian British - Bangladeshi Asian or Asian British – any other Asian background Black or Black British – Caribbean Black or Black British – African Black or Black British – any other Black background Chinese or other Ethnic-Chinese Any other ethnic group
It will also help us to know: Is your child’s first language English?
YES
NO
If NO, what is your child’s first language? …………………………………………………. Thank you for your co-operation. Please return to your local service:
Catshill Clinic, The Dock, Bromsgrove, B61 0NJ Tel: 01527 488326 (Bromsgrove & Redditch) Franche Clinic, Marlpool Place, Kidderminster, DY11 5BB Tel: 01562 752749 (Wyre Forest) Isaac Maddox House, Shrub Hill, Worcester, WR4 9RW Tel: 01905 681592 (South Worcestershire) Bromsgrove & Redditch: 01527 488326
Wyre Forest: 01562 752749
www.hacw.nhs.uk
South Worcestershire: 01905 681592
