Pre School Speech and Language Therapy Referral Form (revised 09/15)
Surname:
Other Names:
Address:
DOB:
Postcode:
Telephone No:
Mobile No:
Does the child have any known allergies?
Yes/No
Please give details:
First Language:
Gender:
Ethnicity:
Religion:
Consent to receive text messages/voice mail
messages
Yes/No
Nursery/Playgroup:
Health Visitor:
Parent/Carers full name:
GP:
NHS No:
Is an interpreter needed?
Has this child been referred to SLT department before:
Is the child known to the Child Development Centre? (CDC)
details):
Yes/No
Yes/No
Yes/No (If yes please give
Relevant development and medical information:
Has child’s hearing been checked? Yes/ No
Has child been seen by audiology?
Results of tests and any ongoing issues with hearing e.g hearing aids/grommets etc:
Yes/ No
Relevant family history:
Summary of Concerns:
Now please complete ALL of Section A and ONE table in Section B (The one that matches the age of the
child being referred)
If you have concerns about a child who is under the age of 2, please discuss these first with the child’s
local Health Visitor who will be able to provide advice and support on the next steps
Any incomplete forms will be returned which can cause a significant delay. Page 1 of 3
SECTION A: Please complete section A for all children and refer to Speech and Language
therapy if you answer ‘yes’ to any of these questions:
Does the child have eating or drinking difficulties?
Yes/ No
Has the child been stammering for at least 6 months?
Yes/ No
Is the child over 3;0 with speech that parents/carers find difficult to understand?
Yes/ No
Is the child over 3;6 and has speech that unfamiliar listeners find difficult to understand? Yes/ No
NB: Children under 5 years will not be seen for lisps or difficulties producing sound blends, e.g. sn, sp, sl, gr, fl, or ‘r’
as this is still age appropriate – Referrals will NOT be accepted for children with these difficulties.
SECTION B: Please complete the ONE table under section B that matches with the age of the child
being referred. Then add up the score.
1. Does the child show / give the correct item when asked
e.g. “where is the ball?” (without the adult looking at the
item)
0
Some
times
1
2. Does the child use approximately 5-20 words?
0
1
2
3. Does the child ask for something by pointing and making
sounds?
0
1
2
4. Does the child play in a pretend way e.g. feed a teddy,
give mum a drink?
0
1
2
5. Does the child use pretend noises e.g. “brrm” for car and
“mooo” for cow?
0
1
2
Child’s Age = 18 - 23 months
Score =
Yes
No
2
If the child scores 6-10 please contact the SLT service to discuss referral on 01895 488 200
1. Does the child put two words together to make a simple
sentence, e.g. ‘me jump’?
0
Some
times
1
2. Will the child point to parts of their body?
0
1
2
3. Can the child correctly follow the adult’s 2 part
instructions ‘give the cup to Sam’ (making sure there is a
choice of item and person so the child cannot guess the
answer by chance)?
4. Does the child play in a pretend way, e.g. filling a truck
with cars/bricks and pushing it along?
0
1
2
0
1
2
5. Does the child understand basic describing words, like
big/small, dirty/clean?
0
1
2
Child’s Age = 2;0-2;5
Score =
Yes
No
Please give examples:
2
score= 4-5 : please discuss extra support with your Health Visitor or local Children’s Centre
score- 6-10 : please send referral to speech and language therapy- see address below
1. Does the child put two words together to make a simple
sentence, e.g. ‘me run’?
0
Some
times
1
2. Does the child use language for a range of reasons e.g.
to comment on things, greet people, ask questions?
0
1
2
3. Can the child correctly follow the adult’s 2 part
instructions ‘give the cup to Jack’(make sure there is a
choice of item and person so that the child cannot guess
the answer by chance)?
4. Does the child play in a pretend way, e.g. having a tea
party with teddy?
0
1
2
0
1
2
5. Does the child show an understanding of in/on/under
and big/little?
0
1
2
Child’s Age = 2;6-2;11
Score =
Please give examples:
Yes
No
Please give examples:
2
score= 4-5 : please discuss extra support with your Health Visitor or local Children’s Centre
score- 6-10 : please send referral to speech and language therapy- see address below
Any incomplete forms will be returned which can cause a significant delay. Page 2 of 3
1. Does the child put three words together to make a simple
sentence, e.g. ‘teddy go park’?
0
Some
times
1
2. Does the child use language for a range of reasons e.g.
to comment on things, greet people, ask questions?
0
1
2
3. Can the child correctly follow the adult’s 3 part
instructions ‘give the big cup to Jack’ (making sure there is
a choice of size, item and person so that the child cannot
guess the answer by chance)?
4. Does the child join in make believe play with other
children, e.g. tea party/ super heroes?
0
1
2
0
1
2
5. Does the child show an understanding of some more
difficult concepts like behind, in front of, colours, size?
0
1
2
Child’s Age = 3;0-3;5
Score =
Yes
No
2
score= 4-5 : please discuss extra support with your Health Visitor or local Children’s Centre
score- 6-10 : please send referral to speech and language therapy- see address below
1. Does the child put three- four words together to tell you
what has happened, e.g. ‘me teddy go park’?
0
Some
times
1
2. Does the child use lots of questions using words like
”what?” and “where?”
0
1
2
3. Can the child correctly follow the adult’s 3 part
instructions ‘give the big ball to teddy’ (make sure there is a
choice of size, item and person so the child cannot guess
the answer by chance)?
4. Does the child join in make believe play with other
children, e.g. tea party/ super heroes?
0
1
2
0
1
2
5. Does the child show an understanding of harder
concepts, e.g. behind, in front of, colours, size?
0
1
2
Child’s Age = 3;6-3;11
Score =
Yes
No
Please give examples:
2
score= 4-5 : please discuss extra support with your Health Visitor or local Children’s Centre
score- 6-10 : please send referral to speech and language therapy- see address below
1. Can the child hold a conversation about things that have
already happened or are going to happen i.e. Talk about
past and future?
2. Can the child answer ‘wh’ questions appropriately? E.g.
“what” “where” “who”?
3. Does the child use grammatical words, e.g. I, his, hers,
past/future tenses?
0
Some
times
1
0
1
2
0
1
2
4. Can the child use complex imaginative play sequences,
e.g. pretending a rock is a magical book?
0
1
2
5. Does the child understand more abstract language
concepts such as first/next/last?
0
1
2
6. Does the child use a range of words to describe how
they are feeling, e.g. angry/sad/happy?
0
1
2
Child’s Age = 4;0-5;0
Score =
Please give examples:
Yes
No
Please give examples:
2
score= 4-5 : please discuss extra support with your Health Visitor or local Children’s Centre
score- 6-10 : please send referral to speech and language therapy- see address below
All referrals must be discussed and agreed with the parents
Date:
I have discussed this referral with the parents and parental consent was given:
Please complete all details below CLEARLY:
Yes / No
Referrer’s name: ….………………………………………………………………………………………....….
Referrer’s role & base: …………….…………………………………………………………………………..
Speech and Language Therapy
Central Referral & Messaging Service
1st Floor Kirk House, 97-109 High Street, Yiewsley, UB7 7HJ
Tel: 01895 488 200/ Fax: 01895 488 865
Any incomplete forms will be returned which can cause a significant delay. Page 3 of 3