Communicate SLT CIC
Request for Speech and Language Therapy

Name of child / young person *

(referred to as child from now on)

Child’s DOB (Date Of Birth) *

Parents / carers names *

Relationship to the child *

Does the child hear or speak a language/s other than English at home? *

If yes, which language/s are spoken heard at home?

Is an interpreter needed for adult or child? *

If so which language should the interpreter speak / understand?

Search by Postcode

Home address line 1 *

Town

County

Country

Postcode

Home telephone / mobile number *

Education Setting

Education setting name *

Teacher / class *

Search by Postcode

School address line 1 *

School town

School county

School country

School postcode

Information

Concerns from professionals involved *

(List any concerns from education staff or others)

Concerns expressed by the family *

(List any concerns expressed by the young person, parents, carers or others in the family)

Impact of these difficulties upon the child/young person *

(in relation to their learning, social relationships and wellbeing)

Relevant medical history and support/medication in place *

(please include recent hearing, vision test, allergies and medical diagnosis including Asthma, ADHD, Autism, Epilepsy, mental health, learning disability, physical needs, other)

Agencies Involved and contact details *

(Speech and Language Therapist, Occupational Therapy, Physiotherapy, Paediatrician, Social Services, Advisory Teachers' Education Psychology, CAMHS)

Details of any previous Speech and Language Therapy Involvement *

Are there any wider family circumstances or safeguarding concerns? *

Who to contact to discuss if relevant?

Information about current skills

Area of concern	Below age expectations	Meeting age expectations	Above age expectations
Attention and listening
Play
Understanding of language concepts
Understanding of questions
Vocabulary learning and use
Sentence construction
Speech pronunciation
Social interaction (e.g. start, maintain and end interactions)
Non-verbal communication (e.g. turn taking, eye contact)
Stammering
Behaviour
Other

WellComm Screening Scores (if available)

Please advise if you can provide either an Early Years or Primary WellComm Score, or neither

NB. If you confirm any WellComm assessment is available, please be advised we expect to see all scores and details of which questions the child/young person got wrong, from and including their age appropriate section back to the section that the WellComm score shows green. If you cannot supply this detail in full, please advise ‘Unable to complete a WellComm score’ and the Communicate SLT CIC team will contact you in due course to assist with this*

Documents

Please attach relevant documentation

Signed parental consent form Education targets/plans Professional reports for all agencies involved EHCP documentation

Referrer Details

Referrer name *

Role or relationship with the child or young person? *

Email *

Contact telephone number

Contact address

Consent

Consent *

I confirm that I have discussed this request for service with a parent of / person with parental responsibility for this child / young person and that they have understood and given consent.

*** Parental consent needs to be given for the request to be accepted ***

Communicate SLT CIC Request for Speech and Language Therapy