Adult Speech and Language Therapy Referral Form

Please use the form below to make a speech and language therapy referral and fill in as much information as possible. Please note, this form can not be saved and returned to, and will time out in the event of inactivity after 60 minutes.

Are you referring yourself?

Yes No

Which area does the patient live in?

Northumberland North Tyneside

Have they had a learning disability since childhood?

Yes No

Patient Details

Name of patient being referred Date of birth
Click into the input field to bring up the date selector or type the date.Age: 0

Patient is not over 18 click here for Paediatric SLT service

Please check that date of birth is entered correctly.

NHS number

Address 1 Address 2 City / Town PostCode Contact Number Email address of patient to contact Please enter valid email address.

GP Practice

Address

Are they in a care home?

Yes No

Care Home

Interpreter required?

Yes No

Please provide details:

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Are you aware of any reason why a lone worker should not visit?

Yes No

Please provide details to enable safe working:

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Are you aware of any infection control requirements for the patient being referred?

Yes No

Please provide details:

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Has the patient consented to the referral?

Yes No They don't have capacity to understand and decide about the referral

Please seek consent from the patient.

**We will assume that you are referring the patient in their best interests.

Please consult key people to make best interest decision.

Referrer Details

What is your name? What is your relationship / role to the patient being referred? Please provide your contact details

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Please provide your email address if you would like an acknowledgement Please enter valid email address

Reason For Referral

Is this referral for help with communication?

Yes No

Please describe the problem of concern:

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Is this a new problem for the patient?

Yes No

Is help needed with capacity assessment / best interests decision?

Yes No

Please describe the problem of concern and its history:

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Is this referral for help with eating / drinking / swallowing?

Yes No

Please describe the problem of concern and its history:

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Is there increased / frequent coughing?

Yes No

Are there frequent chest infections?

Yes No

Is there reduced food / fluid intake?

Yes No

Is there reduced ability to take medication?

Yes No

Has there been any choking episodes?

Yes No

What have you tried so far to help the situation?

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Please provide any relevant medical history.

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Please provide any relevant information about the patients home situation.

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Please complete the required fields to continue.

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Date of Referral

Are you referring yourself?

Which area does the patient live in?

Have they had a learning disability since childhood?

Patient Details

Name of patient being referred

Date of birth

Age :

NHS number

Address

Contact Number

Email address

GP Practice

Interpreter required?

Are you aware of any reason why a lone worker should not visit?

Are you aware of any infection control requirements for the patient being referred?

Referrers Details

Has the patient consented to the referral?

What is your name?

What is your relationship/role to the patient being referred?

Please provide your contact number

Please provide your email address if you would like an acknowledgement

Reason for referral

Is this referral for help with communication?

Is this referral for help with eating / drinking / swallowing?

What have you tried so far to help the situation?

Please provide any relevant medical history

Please provide any relevant information about the patients home situation

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The Speech and Language Therapy Service uses electronic record keeping systems used by other professionals in health and social care in order to enable safe and high quality care.

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