Referred by (name, address and relationship to child)

Reason for referral

Hearing: Does your child have any hearing difficulties?  Has your child had a hearing assessment? 

Vision: Does your child have any visual difficulties? Has your child had a visual assessment? 

Developmental milestones: Provide the age that your child reached these milestones: sitting, crawling, walking, first word, combining words, using sentences     

Social skills:  How does your child get on with other people?  (peers, older children, younger children, adults, teachers)

Family History: Are there any speech/language/learning/literacy difficulties in the immediate or extended family?

Speech and Language Therapy:  Has your child received speech and language therapy before?  What was the result?

Other professionals involved:  Has your child had an assessment with any other professionals e.g. Occupational Therapist, Psychologist, Neurologist?

Other information

Please note:

·         A parent/carer/teacher must be present with the child for the duration of the Speech and Language Therapy session.

·         Payment for the session is to be made at the time of booking.  If you are claiming through health insurance, payment must be made to the therapist and then reclaimed by the parent.

·         Cancellations must be made at least 24 hours before a planned session.  Late/missed cancellations will be charged at the full rate.  By submitting this form you are agreeing to this condition.

·         Please read the GDPR information on the website.  By submitting this form, you are agreeing that you have read and understood the GDPR information.

Consent: I consent to the Speech and Language Therapist to have access to relevant reports and documents in relation to my child and to speak to relevant parties such as school staff and other professionals in order that she can provide the most appropriate treatment plan.

Provide your name and your relationship to the child if you consent.