Name and phone number of Social Worker (if involved) ... Phone number: 01925 251389 .... Child has a persistently hoarse
SPEECH & LANGUAGE THERAPY REFERRAL Child’s name _______________________________ Male / Female__________ d.o.b._____________ Address ____________________________________________________________________________ Postcode ___________ Tel: ___________ Mob________________ GP Name____________________ Parent / Legal Guardian First name and Surname___________________________________________ Name and phone number of Social Worker (if involved)_______________________________________ School / Nursery / Playgroup / Preschool name _____________________________________________ Ethnic Category ______________________________NHS Number (if known) ____________________ Main language spoken in the home ________________
Interpreter needed Yes/No
Please note: For children with English as an additional language refer if limited progress made with English after 6 months in regular attendance in an English speaking environment. Please tick preferred Clinic: Grappenhall
Sandy Lane, Orford
Wolves
General concerns, educational assessments or information on medical problems? If you have any concerns about Hearing please refer for a Hearing Test
Other professionals involved: Does this Parent have any disabilities? Does this child have any disabilities other than communication? To refer please send this page + the parental consent page + one page for the child’s age to the address below.
Referrers Printed Name: _____________________________
Base: ________________________
Designation: _______________________ Contact No: ____________ Date: __________ Health staff: send copy to GP and file.
Return to: Speech and Language Therapy, Health Services at Wolves, The Martin Dawes Stand, Winwick Road, WA2 7NE Phone number: 01925 251389 Form issued January 2011.
CONSENT FOR REFERRAL TO SPEECH AND LANGUAGE THERAPY
Child’s Name: ………………………………… D O B: ……………………………..
Confidentiality of my child’s information and consent to sharing of this information has been discussed with me by
Tick
______________________
YES NO
Print Name
I understand that it will help my child if I give my consent for Warrington Speech and Language Therapy Dept to share all speech and language therapy information, reports and programmes with:
Relevant Health care staff
YES
Tick NO
Relevant Education and Children Centre staff
YES
NO
I give my consent to share information relating to my child’s appointment times and attendance at appointments with the above people Tick YES
NO
I give consent to Speech and Language Therapists to ask the above people for further information about my child where required for my child’s Speech and Language treatment. Tick YES
NO
As part of our role we train students. I understand that students may be present in my child’s sessions. I have had the issue of consent fully explained to me, and I understand that I am under no obligation to give consent to any of the above. I have ticked where I have given consent.
Name ………………………..………
Date ……………………………….……
Signature ……………………………
Relationship to child ………………………….. (Next of kin / Legal Guardian only)
Child’s Name: _______________________
1.
0 – 17 months age sheet
By 9 months Child is very quiet, has no babble (eg bababa or mamama) or makes a very limited range of sounds eg uses ‘guh’ or ‘da’ for everything
Yes
2.
By 15 months Child can only name 1 or 2 objects
Yes =
3.
Child has a developmental delay or possible evolving complex needs or syndrome e.g. cleft palate, cerebral palsy sensori-neural hearing loss, Down’s syndrome
Yes
=
Refer
Yes
=
Refer
Yes
=
Refer
4.
Child has very limited interaction e.g. child does not point or make requests by pointing or showing. Child may often be considered ‘in a world of their own’
5.
Child has a swallowing problem of a mechanical nature (not behavioural)
=
Refer Refer
In order to make a referral for this reason you will need to have observed the child eating and drinking and noted one or more of the following a. b. c. d.
Uncoordinated swallow resulting in child coughing or choking. Observation of repeated throat clearance around mealtime. Observation of eye watering or facial reddening during mealtime. Wheezing or “gurgly” sounds around mealtime.
In addition this Child’s history may include any or all of the following: history of failure to thrive complex medical history eg developmental delay, downs syndrome, cerebral palsy history of chest infections or may be having treatment for asthma or cyanotic episodes
Referral for behavioural feeding problems (eg if child is able to manage a range of food textures successfully but prefers to eat a limited range of tastes such as crisps or chicken nuggets) are not appropriate. If the child is vomiting frequently and therefore refusing food they should be referred either to their GP or to a Paediatrician for medical investigation rather than to Speech and Language Therapy / Feeding clinic.
Form issued January 2011
Child’s Name: _______________________
1.
18 – 24 months age sheet
Child has very limited expressive language i.e.
By 18 months child has at least 8 words
No
=
Refer
By 21 months child has at least 20 words
No
=
Refer
By 24 months child has at least 40 words
No
=
Refer
By 18 months child can point to at least 1 body part (e.g. nose, hair)
No
=
Refer
By 21 months child can select at least 3 familiar objects from a small choice
No
=
Refer
By 24 months child can select at least 5 familiar objects from a small choice
No
=
Refer
3.
Child mouths or bangs toys together rather than using toys to pretend (e.g. putting a hairbrush in their mouth rather than brushing their own hair)
Yes
=
Refer
4.
Child communicates on his / her own terms i.e. mostly to ask for items. It is very difficult to draw child’s attention to things
Yes
=
Refer
2.
Child has difficulty understanding simple spoken language (ie when adult using no gesture or pointing)
Form issued January 2011
Child’s Name: _______________________
1.
2.
2:1 – 2:6 years age sheet
Child has very limited expressive language i.e. By 25 months child can use 45 words and 2 word links
No
=
Refer
By 30 months child can regularly put 2 words together
No
=
Refer
By 25 months child can select at least 5 familiar objects / body parts and follow at least 3 actions (sleep, jump, sit down)
No
=
Refer
By 30 months child can follow instructions containing 2 pieces of information
No
=
Refer
Child has difficulty understanding simple spoken language (i.e when adult using no gesture or pointing )
e.g.
Where’s Mummy’s hair? Where’s child’s shoes?
3.
Child is able to play with toys in a pretend way (i.e. can pretend to brush Mummy’s hair or feed a toy)
No
=
Refer
4.
Child communicates on his / her own terms i.e. mostly to ask for items. It is very difficult to draw child’s attention to things
Yes
=
Refer
5.
Child has unusual or obsessive interests in particular types of play (e.g. lining toys up, excessive spinning of toys, special interest in washing machines or other electrical equipment)
Yes
=
Refer
6.
Child regularly but inappropriately says learned phrases eg from a favourite DVD
Yes
=
Refer
7
Child’s sentences are often disrupted by 3 or more repetitions of parts of words or short words e.g. “bi-bi-bi-biscuit”, “can can can can can I have”. Child often struggles to get words out e.g. stops and then pushes the word out with effort.
Yes
=
Refer
8
Child or parents show concern or distress re stammering
Yes
=
Refer
9.
Child has a persistently hoarse voice or abnormal vocal quality
Yes
=
Refer
Child’s Name: _______________________
2.7 – 3.0 years age sheet
1.
Child is consistently using 3 to 4 words together e.g. “mummy go shop”, “want more juice now”
No
=
Refer
2.
Child can follow simple verbal instructions containing 2 key words without visual clues (adult using no gesture or pointing) No
=
Refer
e.g.
“Push the chair” “Jump to the door”
“ Point to Mummy’s shoe” 3.
Child regularly but inappropriately repeats learned phrases e.g. from a favourite TV programme or conversation or child repeats what you say rather than responding to you
Yes
=
Refer
4.
Child has own agenda i.e. communicates / plays only on own terms and it is difficult to draw child’s attention to what you are pointing to. Child has poor eye contact.
Yes
=
Refer
5.
Child’s speech can only be understood by family i.e. child uses a very restricted range of sounds or unusual sounds.
Yes
=
Refer
6.
Child’s sentences are often disrupted by 3 or more repetitions Yes of parts of words or short words e.g. “bi-bi-bi-biscuit”, “can can can can can I have”. Child often struggles to get words out e.g. stops and then pushes the word out with effort.
=
Refer
7.
Child or parents show concern or distress re fluency (stammering).
Yes
=
Refer
8.
Child has a persistently hoarse voice or abnormal vocal quality
Yes
=
Refer
Form issued January 2011
Child’s Name: __________________________
3.1 - 3.6 years age sheet
1.
Child uses at least 180 words and uses lots of verbs (action words e.g. jump).
No
=
Refer
2.
Child puts at least 5 to 6 words together when speaking
No
=
Refer
3.
Child is not following instructions that peers follow and / or relies on watching and following what others do.
Yes
=
Refer
4.
Child passes screening for understanding on 3 year check
No
=
Refer
5.
Child responds inappropriately to questions and cannot have a a simple conversation. Child repeats what you say rather than responding
Yes
=
Refer
6.
Child prefers to play alone and rarely initiates interaction with others.
Yes
=
Refer
7.
Child’s family or teachers cannot understand most of what is said e.g. child is using a restricted speech sound range or misses sounds off at ends of words e.g. cat Æ ca.
Yes
=
Refer
(It is too early to refer mispronunciations of ‘r, th, l, ch, sh, f, s, k, g )
8.
Child’s sentences are often disrupted by 3 or more repetitions of parts of words or short words e.g. “bi-bi-bi-biscuit”, “can can can can can I have”. Child often struggles to get words out e.g. stops and then pushes the word out with effort
Yes
=
Refer
9.
Child or parents show concern or distress re fluency (stammering)
Yes
=
Refer
10
Child has a persistently hoarse voice or abnormal vocal quality Yes
=
Refer
Form issued January 2011
Child’s Name: __________________________
3.7 – 4.6 years age sheet
1.
Child can easily retell a simple story or event including use of grammatical words like “is”, “the”.
No
=
Refer
2.
Child can follow long or more complex instructions with a number of steps e.g. “Put your books away and sit at the table”
No
=
Refer
3.
Child can easily answer who, what, where questions
No
=
Refer
4.
Child has limited imaginative play or repetitive behaviour, has poor social interaction, poor eye contact and/or difficulty maintaining conversation on a range of topics. Child cannot take turns in conversation
Yes
=
Refer
5.
Child has a very limited vocabulary and / or regular difficulty thinking of the right word. Child over uses non specific words like “that thing”, “thingy”, “it”
Yes
=
Refer
6.
Family and Teachers find the child‘s speech very difficult to understand.
Yes
=
Refer
7.
Child does not use t,d,s,f,k,g sounds consistently in words or is using unusual sounds in speech e.g. slushy /s/
Yes
=
Refer
(It is too early to refer mispronunciations of ‘r, th, l, ch, sh and consonant blends e.g. stop, blue etc.) 8.
Child’s sentences are often disrupted by 3 or more repetitions of parts of words or short words e.g. “bi-bi-bi-biscuit”, “can can can can can I have”. Child often struggles to get words out e.g. stops and then pushes the word out with effort
Yes
=
Refer
9.
Child or parents show concern or distress re stammering.
Yes
=
Refer
10.
Child has a persistently hoarse voice or abnormal vocal quality
Yes
=
Refer
Form issued January 2011
Child’s Name: _______________________
4.7 – 5.6 years age sheet
1.
Child can follow instructions containing sequencing concepts e.g. before/after, first/last without relying on watching his peers.
No
=
Refer
2.
Child can remember long instructions without needing repetition.
No
=
Refer
3.
Child is easily able to answer “why” questions
No
=
Refer
3.
Child is easily able to explain events so the listener knows what happened without being there
No
=
Refer
4.
Child has a very limited spoken vocabulary and / or regular difficulty thinking of the right word. Child over uses non specific words like “that thing”, “thingy”, “it”
Yes
=
Refer
5.
Child is difficult to understand due to many pronunciation errors including ch, sh.
Yes
=
Refer
(It is too early to refer mispronunciations of “r, th, l,” ) 6.
Child has poor social interaction with peers, has poor eye contact, cannot take turns in conversation or jumps inappropriately from one topic to another.
Yes
=
Refer
7.
Child’s sentences are often disrupted by 3 or more repetitions of parts of words or short words e.g. “bi-bi-bi-biscuit”, “can can can can can I have”. Child often struggles to get words out e.g. stops and then pushes the word out with effort
Yes
=
Refer
8.
Child or parents show concern or distress re stammering.
Yes
=
Refer
9.
Child has a persistently hoarse voice or abnormal vocal quality.
Yes
=
Refer
10.
Child is reluctant to speak to teachers / peers at school or reluctant to speak to adults at home
Yes
=
Refer
Form issued January 2011
Child’s Name: _______________________
5. 7 – 7.0 years age sheet
1.
Child is often confused when given whole class and individual instructions and has difficulty following and demonstrating understanding of stories read aloud.
Yes
=
Refer
2.
Child has difficulty following a conversation and often misinterprets meaning.
Yes
=
Refer
3.
Child often has difficulty when trying to express himself in a logical coherent manner. Child takes a long time to organise ideas into words and sentences (Sentences are disjointed and lacking in content, frequently uses words like ‘thingy’ ‘it’ ‘that’ ‘there’ rather than being specific; seems to start in the middle of a story)
Yes
=
Refer
4.
Child can be very repetitive and mainly talks about a single topic of conversation or constantly jumps from one topic to another without appreciating the situation.
Yes
=
Refer
5.
Child has significant difficulty interacting with peers and making friends and constantly misinterprets social situations.
Yes
=
Refer
6.
Child’s sentences are often disrupted by 3 or more repetitions of parts of words or short words e.g. “bi-bi-bi-biscuit”, “can can can can can I have”. Child often struggles to get words out e.g. stops and then pushes the word out with effort
Yes
=
Refer
7.
Child or parents show concern or distress re stammering.
Yes
=
Refer
8.
Child’s speech is difficult to understand
Yes
=
Refer
9.
Child has a persistently hoarse voice or abnormal vocal quality
Yes
=
Refer
10
Child is reluctant to speak to teachers / peers at school or reluctant to speak to adults at home
Yes
=
Refer
Form issued January 2011
Child’s Name: _______________________
7.1 – 11. 11 years age sheet
Apart from speech sounds these children could have been referred at a younger age. At this age it is likely that advice, class room strategies and a programme for school will be most appropriate to meet needs
1.
Child is often confused when given whole class and individual instructions and has difficulty following and demonstrating understanding of stories read aloud.
Yes
=
Refer
2.
Child has difficulty following a conversation and often misinterprets meaning.
Yes
=
Refer
3.
Child has difficulty understanding irony, sarcasm or humour.
Yes
=
Refer
4.
Child often has difficulty when trying to express him /herself. Sentences are disjointed and lacking in content. Child frequently uses words like “thingy”, “it”, “that”, “there” rather than being specific.
Yes
=
Refer
5.
Child has difficulty giving logical explanations and/or in telling logical, coherent stories.
Yes
=
Refer
6.
Child can be very repetitive and mainly talks about a single topic of conversation or constantly jumps from one topic to another without appreciating the situation.
Yes
=
Refer
7.
Child has significant difficulty interacting with peers and making friends.
Yes
=
Refer
8.
Child continues to have persistent problems with pronunciation of speech sounds
Yes
=
Refer
9.
Child or parents show concern or distress re: stammering.
Yes
=
Refer
10.
Child has a persistently hoarse voice or abnormal vocal quality
Yes
=
Refer
11
Child is reluctant to speak to teachers / peers at school or reluctant to speak to adults at home
Yes
=
Refer
Form issued January 2011
Child’s Name: _______________________
12.0 – 15. 11 years age sheet
At this age, following assessment, it is likely that advice and class room strategies will be most appropriate to meet needs 1.
Child is often confused when given whole class and individual instructions and has difficulty following and demonstrating understanding of material read aloud.
Yes
=
Refer
2.
Child has difficulty following a conversation and often misinterprets meaning. In conversation, constantly moves quickly from topic to topic or stays on one topic for far too long
Yes
=
Refer
3.
Child has difficulty understanding irony, sarcasm or humour.
Yes
=
Refer
4.
Child often has difficulty when trying to express him/ herself. Sentences are disjointed and lacking in content and s/he may take a long time to organise words into sentences.
Yes
=
Refer
5.
Child has difficulty giving logical explanations and/or telling logical, coherent stories. Uses awkward grammar
Yes
=
Refer
6.
Child can be repetitive and single minded in a choice of conversational topics without appreciating the situation
Yes
=
Refer
7.
Child has significant difficulty interacting with peers and making friends.
Yes
=
Refer
8.
Child has persistent problems with pronunciation of speech sounds. Can speak far too fast so words run into each other
Yes
=
Refer
9.
Child or parents show concern or distress re: stammering.
Yes
=
Refer
10.
Child has a persistently hoarse voice or abnormal vocal quality
Yes
=
Refer
11
Child is reluctant to speak to teachers / peers at school or reluctant to speak to adults at home
Yes
=
Refer
Form issued January 2011
