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Chair: Barbara Vann Chief Executive: Phillip ConfueHead Office: Fairview House, Corporation Road, Bodmin, Cornwall, PL31 1FBTel: 01208 251300 Email: CFTenquiries@Cornwall.NHS.UK

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Children’s Speech and Language Therapy Referral

For help in filling out this form or if you are unsure whether a referral should be made, please contact the Speech and Language Therapy Helpline on 01208 834488.

Child/Young Person Details

Name: DOB: Sex: M F

Address:

Postcode:

NHS Number:

Telephone:

Mobile:

Parent/Carer Names:

If a mobile number is supplied you will receive appointment reminders by text message.

Parent/carer email:

GP/Surgery:

Preschool or school:

Contact Number:

Contact Name:

Home Language:

Additional Language(s):Interpreter Required: YES NO

Child/Young Person Ethnicity:

White British ☐ Mixed White/Black Caribbean ☐ Asian British Pakistani ☐

Cornish ☐ Mixed White & Black African ☐ Asian British Bangladesh ☐

White Irish ☐ Mixed White & Asian ☐ Any Other Asian Background ☐

Any Other White Background ☐ Any Other Mixed

Background ☐ Black British Caribbean ☐Black British African ☐ Any Other Black Background ☐ Any Other Ethnic Group ☐Chinese ☐ Asian British Indian ☐Consent: To be signed by the child’s parent or guardianI give permission for this referral to be made and for the speech and language therapy service to assess & treat my child. I also consent to the sharing of information and reports about my child between the speech and language therapy service and other relevant professionals / services, in order for them to provide the most appropriate intervention.Privacy Statement

The information you provide is being collected by Children, Schools and Families Early Help Hub (EHH) for the purpose of helping us to make the right decisions about the type of service you need ensuring you receive services best suited to your needs and circumstances

This information may also be shared with other relevant professionals in conjunction with the nature of the request or enquiry. The data held relating to the delivery of support by EHH to your child will be used both for the provision of services and also for performance and service planning. This information will be held in a secure environment in line with the Information Governance Alliance Records Management Code of Practice for Health & Social Care 2016, upon reaching the relevant retention the information will be appraised and if relevant destroyed in a secure manner. A full copy of our Trust Privacy Notice can be found athttp://www.cornwallft.nhs.uk/about/information-governance/privacy-notice-patients/

Chair: Barbara Vann Chief Executive: Phillip ConfueHead Office: Fairview House, Corporation Road, Bodmin, Cornwall, PL31 1FBTel: 01208 251300 Email: CFTenquiries@Cornwall.NHS.UK

Passionate about our servicescornwallfoundationtrust.nhs.uk

Signed: Name: Date:If you DO NOT wish to receive copies of reports about your child please tick: ☐Verbal Consent: For use of Health Professionals only

The referrer has gained verbal consent for:This referral to be made and for an assessment to take place.

The sharing of information between professionals and services who are

part of the Early Help Hub response.

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Reason for referralPlease refer to ‘When to be concerned’ leaflets - available on Cornwall NHS Children’s Speech and Language Therapy Website (put this term into an internet search). These leaflets will give an overview of the types of difficulties the service is able to offer support for.

If you are unsure whether a referral needs to be made, please contact the Speech and Language Therapy Helpline on 01208 834488 before sending in a referral form. This is a telephone call back service from a qualified SLT.

Referrer DetailsName: Role:

Tel: Email:

Date of referral:

Address:

Why are you making the referral? What would you like help with?

What support has already been put in place for the child/young person?

Has the child/young person been seen by the SLT department before? If please give details of when seen:

Eating, Drinking and Swallowing Needs

If your only concern is difficulties with eating, drinking and swallowing fill in this section. If you have concerns about communication and eating, drinking and swallowing, fill in this section and the relevant age section below. Please describe the child/young person’s difficulties with eating and drinking:

Chair: Barbara Vann Chief Executive: Phillip ConfueHead Office: Fairview House, Corporation Road, Bodmin, Cornwall, PL31 1FBTel: 01208 251300 Email: CFTenquiries@Cornwall.NHS.UK

Passionate about our servicescornwallfoundationtrust.nhs.uk

Speech, Language & Communication Needs

Communication Skills - Please fill in one section relating to the child/young person’s age and then continue to background information section.

Age Information

Under 24 months

Referrals can only be made by Paediatricians and Early Years Inclusion Team. Please put details in reason for referral section above or attach a clinical letter.

Contact the SLT helpline for advice 01208 834488 if you have concerns about a child under 2 years that does not meet the above criteria. Referrals for eating, drinking and swallowing for under 2’s can be made by anyone – please fill in section above.

Stammering/Stuttering/Dysfluency

Are there concerns about stammering/stuttering/Dysfluency that have been present for more than 2 months? If yes, please provide details:

If there are also concerns with another area of communication please complete the next section.

Eating, Drinking and Swallowing Needs

If your only concern is difficulties with eating, drinking and swallowing fill in this section. If you have concerns about communication and eating, drinking and swallowing, fill in this section and the relevant age section below. Please describe the child/young person’s difficulties with eating and drinking:

Chair: Barbara Vann Chief Executive: Phillip ConfueHead Office: Fairview House, Corporation Road, Bodmin, Cornwall, PL31 1FBTel: 01208 251300 Email: CFTenquiries@Cornwall.NHS.UK

Passionate about our servicescornwallfoundationtrust.nhs.uk

2 years 0 months to 2 years 11 months

Please do not refer children for unclear speech in this age group.

Child is using less than 10 spoken words (count all words even if they are unclear e.g. gaga for Grandad)

List words here:

AND please tick if any of the following risk factors apply:

☐ The child does not copy sounds, actions or words e.g. animal sounds, actions in songs, “uh oh”, pointing to what they want to say.

☐ The child does not understand spoken language e.g. unable to point to body parts when asked; unable to follow a basic instruction, e.g. get your shoes.

☐ The child has limited play skills e.g. does not make pretend tea, does not act out scenes with toys; plays unusually with toys, e.g. spinning items, repeating the same play sequences.

☐ The child shows little or no interest in communicating with others e.g. limited eye contact or pointing.

☐ Limited change over time e.g. when a member of the health visiting team reviews the child’s progress after 3 months or more.

☐ There is a family history of difficulties with language development.

3 years 0 months to 3 years 5 months

☐ The child cannot follow a short verbal instruction.

☐ The child is only using single words or two-word sentences.

☐ The Child has unusual or obsessive interest in certain types of play, e.g. excessive spinning of toys.

☐ The child has poor social skills, e.g. difficulty initiating & playing with other children; AND uses limited eye contact & pointing.

☐ The child’s talks confidently at home but does not talk at all in preschool/other setting.

☐ Parents/carers are not able to understand the child most of the time. If yes, fill in the speech sample below.

Speech Sound Sample – write down how your child says these words:

Cat: Fish: Lion: Blue:

Spider: Dog: Fork: Man:

Table: Sauce: Green: Chips:

Chair: Barbara Vann Chief Executive: Phillip ConfueHead Office: Fairview House, Corporation Road, Bodmin, Cornwall, PL31 1FBTel: 01208 251300 Email: CFTenquiries@Cornwall.NHS.UK

Passionate about our servicescornwallfoundationtrust.nhs.uk

Sun: House:

Other words:

3 years 6 months to 4 years 5 months

☐ The child is not able to follow basic verbal instructions.

☐ The child is not regularly using 4 – 5 word sentences. If yes, please give examples of phrases/sentences the child is using:

☐ The child has poor social interaction skills – please indicate areas of concern:- limited imaginative play - repetitive behaviours- poor eye contact - difficulty turn-taking- obsessive about certain topics - difficulty maintaining conversation

☐ Parents/carers are not able to understand the child most of the time. If yes, please fill in the speech sound sample section above.

☐ The child’s talks confidently at home but does not talk at all in preschool/other setting.

Over 4 years 6 months

The child has unclear speech. If yes, please fill in the speech sound sample section above and write any further comments in the other information box below.

If there are additional or other concerns please comment in one or more of the boxes below giving examples of how the child’s communication impacts their day to day life:

Comprehension - Difficulties understanding what is said & following instructions

Expressive language - Difficulties expressing him/herself using appropriate vocabulary and sentences, talks at home but not at school/other setting.

Social interaction - Difficulties interacting appropriately with peers and adults verbally & non-verbally

Voice - Unusually hoarse / croaky voice / loud / quiet voice.

Chair: Barbara Vann Chief Executive: Phillip ConfueHead Office: Fairview House, Corporation Road, Bodmin, Cornwall, PL31 1FBTel: 01208 251300 Email: CFTenquiries@Cornwall.NHS.UK

Passionate about our servicescornwallfoundationtrust.nhs.uk

Any Other Information

Background Information

Child’s Current Family & Social Situation:Who lives at home with the child?Parents: Siblings: Others:

Other significant adults or family members with regular contact?

Please provide any relevant details about the family or child (e.g. culture, traveller community, HM forces, ethnicity, learning or literacy needs, recent changes in circumstances, accessing short breaks etc):

Safeguarding: Child In Need ☐ Child Protection Plan ☐ Other ☐Has a CAF / TAC / Early Support been initiated for this child?

If yes, give lead professional’s details:

Chair: Barbara Vann Chief Executive: Phillip ConfueHead Office: Fairview House, Corporation Road, Bodmin, Cornwall, PL31 1FBTel: 01208 251300 Email: CFTenquiries@Cornwall.NHS.UK

Passionate about our servicescornwallfoundationtrust.nhs.uk

Child’s Medical Information:Details of any medical conditions, diagnoses or developmental delay (e.g. delayed milestones, learning difficulties, ASD, vision, hearing, asthma, allergies, epilepsy)

Date of last hearing test: Outcome of last hearing test:

Details of any medication taken by the child:

Does the child experience frequent or recurrent ear, throat or chest infections? (Provide details about frequency & treatment received).

Child’s Educational Information:

Preschool – EYFS levels: School age – National curriculum/P-levels:

Does the child have an ECHP in place?

If preschool: When did the child start in current setting?

What days/sessions do they attend?

Does the child attend any other settings? (please give details)

Chair: Barbara Vann Chief Executive: Phillip ConfueHead Office: Fairview House, Corporation Road, Bodmin, Cornwall, PL31 1FBTel: 01208 251300 Email: CFTenquiries@Cornwall.NHS.UK

Passionate about our servicescornwallfoundationtrust.nhs.uk

Current Situation:Parents & referrer to rate where the child is now – please tick(0 = not at all / never and 10 = extremely / always)

1 How concerned are the child’s parents about his/her speech and language difficulties?

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2 How concerned is the referrer about the child’s speech and language difficulties?

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3 How much are the child’s communication difficulties affecting his/her ability to interact with / talk to / get along or play with others in everyday situations?

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4 How much do you think the child’s speech or language difficulty is affecting their ability to access the curriculum, including Foundation Stage?

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5 How often is the child becoming frustrated, angry or withdrawn due to their communication difficulty?

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6 How aware is the child that he/she has a difficulty with communication?

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Send this form to the Early Help Hub: Email (please put Speech and language therapy referral in the subject box): earlyhelphub@cornwall.gov.uk

Telephone enquiries: 01872 322277 Monday to Thursday 8.45am to 5.15pm, Friday 8.45am to 4.45pm, or visit the website www.cornwall.gov.uk/earlyhelphub