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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?

Patient Details


Patient is not over 18 click here for Paediatric SLT service

Please check that date of birth is entered correctly.

GP Practice

Reason For Referral


Is this referral for help with communication?

Total word count: 0 words. Words left: 250
Total word count: 0 words. Words left: 250

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

Total word count: 0 words. Words left: 250
Total word count: 0 words. Words left: 250
Total word count: 0 words. Words left: 250


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Date of Referral

Are you referring yourself?

Which area does the patient live in?

Have they got learning disabilities?

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 shouldn't 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?

Please provide any relevant medical history

Please provide any relevant information about the patients home situation

The Speech and Langauge 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.

Email security:

When communicating with patients, family, and/or carers by email we need to inform you of the potential risks associated with such methods:

If you provide an email address we will assume this is understood and contact via email is acceptable.

This isnt the correct service for this referral.
We cover North Tyneside and Northumberland.
Please check neighbouring services.

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