CHILDREN’S AUDIOLOGY REFERRAL FORM
Please send this to: The Children & Young People’s Audiology Centre, St
Thomas’ Hospital, South Wing, 2nd Floor, Westminster Bridge Road,
London, SE1 7EH
Tel: 020 3049 8560 Email: [email protected]
(* Mandatory information required)
*Name of Referrer:
*Designation:
* Address of Referrer:
*Phone number and/or email of Referrer:
*Date:
Please circle patient’s GP’s Borough*
Southwark
Lambeth
Lewisham
Bromley
Greenwich
Bexley
OTHER
Specify:
*Child’s surname/family name:
*D.O.B:
*First names:
*Address:
 *Male
 *Female
*Post Code:
*Telephone Numbers:
*NHS Number:
*Name and address of GP:
School (if applicable):
 *Looked after child? Name and Borough of Social Worker:
 Interpreter required (language):
REASON FOR REFERRAL







Failed two hearing screening tests (see over page)
Significant parental concern about hearing**
Professional concern about hearing**
Hearing or listening behaviour not age-appropriate (see parental questionnaire)**
Speech and language delay confirmed by:**
Risk factor(s) for permanent hearing impairment**
Other**
**Please provide further details below:
RELEVANT PAST HISTORY
Normal
Not Normal
Normal
Birth
Pregnancy


Neonatal period


Not Normal


Developmental progress 

Please include any details if “not normal”
DETAILS OF HEARING SCREENING TESTS (if applicable)
Please indicate Pass () or Fail (x) and dates of tests:
TEST 1
NEWBORN HEARING SCREEN
TEST 2
 No  Yes
Date:
PURE TONE SWEEP
(25dBHL)
500Hz
1000Hz
2000Hz
4000Hz
..........
..........
..........
..........
Date:
..........
..........
..........
..........
..........
..........
..........
..........
..........
..........
..........
..........
Other relevant information:
Has the child’s parent/carer given informed consent for this referral?
 Written
 Yes
 Verbal
*Signed: (Referrer) _________________________________________
For more information on our services visit evelinalondon.nhs.uk/audiology
2