Speech and Language Therapy
Assessment Clinic Checklist
Child’s Details
Child’s Full Name
Date of Birth
NHS Number
Address
Postcode
Home Telephone
Home language
Preschool/Nursery
Parent Details
Name of
Parent(s)/Guardian
Relationship to Child
Parental
Yes
Responsibility
No
Contact Details (if
Mobile Number
Ethnicity


different from above)
Referrer Details
Name
Name of work place / organisation
Address
Contact Number
Signature
G.P. Details
Name of GP:
Profession
Date
Address of GP:
Please note that if your GP is not in Bedfordshire
or Luton, we will not be able to see your child.
I agree that during the child’s care:
- this record can be shared with other professionals involved in this child’s care
- the therapist can view information recorded by other professionals
I understand that this information may be shared verbally, in the form of written
reports or via computerised records.
Yes  No

Yes  No

I agree to my child receiving Speech and language therapy input if appropriate
and will attend appointments offered or will notify the therapist as soon as
possible if I am unable to attend my appointment.
Yes  No

The Speech and Language Therapy Service can leave voice messages from the
service on my home/mobile number if I am unavailable.
Yes  No

I would like to receive SMS/Text message reminders for review appointments
Yes  No

Every effort will be made to offer the preferred choice of group/appointment but
unfortunately this cannot be guaranteed.
Name:
Parent/Guardian Signature:
Relation to child:
The following sections must be completed by the person advising attendance and the
child’s parent/guardian.
Please bring the completed form to a Speech and Language Therapy Assessment
Clinic. Please note that children already under the SLT service or awaiting assessments
with the SLT service at the Edwin Lobo CDC or Kempston CDC do not need to attend an
assessment clinic.
Families who do not return the completed form will not be seen by a Speech and
Language Therapist.
Please outline any concerns to support the need for attendance. You may want to comment on attention
and listening, play and interaction skills, understanding, expressive language, speech and fluency. For
settings: please feel free to attach your own reports or observations.
Has this child been to an Assessment Clinic before?
Yes
 Approx.date:
If ‘yes’, what was the outcome?
No

What advice were you given?
Has this advice been carried out?
Yes

No

Medical History
Were there any problems
during…
Pregnancy
Birth
Please Tick
Details
Yes
Yes


No
No


Yes
Yes
Yes
Yes
Yes





No
No
No
No
No





Has your child had…
Frequent coughs, colds
Ear infections
Mumps/Measles/chicken pox
Any stay in hospital
Any allergies
Hearing
Has your child got/had a hearing difficulty?
Yes
Date of most recent test:
Result:
Are you concerned at the moment about your child’s
hearing?
Yes
Early Development
Sitting
Crawling
Walking
First Words
Joining Words Together
Toileting
Does your child have
any difficulties with
eating or drinking?

No


No

Approximate Age
Day:
Yes


Night: 
No

If yes, please give details:
Has your child ever…
Sucked their thumb
Used a dummy
Still use a bottle
Yes
Yes
Yes



Family
Please give names and ages of any
brothers and sisters
Is there any family history of speech or
language difficulties?



No
No
No

No

Yes

No

Yes

No

Yes
Details:
Are you, or is anyone living in the
house, a smoker?
Would you like advice about how to
stop smoking?
PLEASE NOTE: The assessment clinics are run on a ‘first-come, first-served’ system, and if there are too
many children to be seen by the therapist(s) in one session, you will be offered a phone consultation in
the first instance.