To be completed by child's parent/carer
Name of child
* Required
Date of birth
* Required
Name of person completing this form
* Required
Relationship to child
* Required
Name of the child's next of kin
* Required
Contact number for child's next of kin
* Required
What is the main language(s) spoken at home?
* Required
Are there any other languages spoken at home?
* Required
Yes
No
Will you need an interpreter at any appointments we may offer?
* Required
Yes
No
Current concerns
Does your child have any difficulties with listening and concentrating?
* RequiredYes No
If yes, please provide detail
Does your child have any difficulties interacting with other people?
* RequiredYes No
If yes, please provide detail
Does your child have any difficulties understanding what people say?
* RequiredYes No
If yes, please provide detail
Does your child have any difficulties saying sounds and words?
* RequiredYes No
If yes, please provide details including a list of sounds that the child is unable or finds difficult to say
Does your child stammer when they talk? For example, do they repeat the first word or whole words?
* RequiredYes No
If yes, please provide detail
Does your child have any voice difficulties? (For example, their voice is husky or do they whisper when they talk?)
* RequiredYes No
If yes, please provide detail
Is your child unable to speak in certain situations?
* Required
If yes, please provide detail
Does your child have any difficulties putting sounds, words and sentences together to share information, ideas and wishes?
* RequiredYes No
If yes, please provide detail. For example, how many words does your child put together in a sentence?
Does your child have any difficulties with eating or feeding, drinking or swallowing?
* RequiredYes No
If yes, please provide detail
Please add any further details or information in here
Birth history
Were there any complications during the pregnancy?
* RequiredYes No Not Known
Were there any complications during the birth?
* RequiredYes No Not known
Were there any difficulties with feeding in the first year?
* RequiredYes No Not known
Did your child have a dummy/ still use a dummy/ or suck their fingers?
* RequiredYes No Not known
Where you have answered yes to the questions above, please explain and describe what you have observed and/or give examples here. Please provide as much detail as possible to help the speech and language therapist understand your child's difficulties.
Milestones and early development
Did you experience any difficulties moving from liquid feeding to solid foods with your child?
* RequiredYes No
If yes, please provide detail
Do you have any concerns about your child's development, for example do you find they are sometimes clumsy or they struggle to pick up objects? *
* RequiredYes No
If yes, please provide detail
When your child was a baby did they babble a lot?
* RequiredYes No
If yes, please provide detail
When your child was a baby were they particularly quiet?
* RequiredYes No
If yes, please provide detail
When did you your child achieve the following? Please detail the year and month
Sitting
Crawling
Walking
Toilet training
How old was your child when they said their first words? The word doesn't have to be said correctly, just that you knew what your child was saying. Please detail the year and month
* Required
Medical history
Has your child had speech and language therapy in the past?
* Required** None Yes No
If yes, please provide detail
Has your child had any infections / prescribed medication / hospital visits?
* RequiredYes No
If yes, please provide detail
Do you have any concerns about your child's hearing at the moment?
* RequiredYes No
If yes, please provide detail
Since birth, has your child's hearing been checked?
* RequiredYes No
If yes, please provide detail
Has your child had any ear infections in the past?
* RequiredYes No
If yes, please provide detail
Do you have any concerns regarding your child's vision?
* RequiredYes No
If yes, please provide detail
Family history
Are you aware of any history of speech and language difficulty in the family?
* RequiredYes No
If yes, please provide detail
Does your child have any brothers and sisters?
* RequiredYes No
If yes, please provide detail
Did they have any speech and language difficulties?
* RequiredYes No
If yes, please provide detail
Are there any other services or professionals, such as social care or health visitors, working with your child?
* RequiredYes No
Please provide details of the organisation
Socialisation / play
What does your child enjoy doing at home e.g. what play activities do they like, do they like to read, colour, draw - please describe.
Education
Is your child at pre-school or school?
Yes No
Name of pre-school/school and teacher
Times and sessions attended (pre-school children only)
Has the pre-school or school highlighted any concerns to you regarding your child's speech and language? please explain.
Outcomes
What outcomes are you hoping for from the referral to our Speech and Language Therapy Service?
