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Milton Keynes Children’s Speech and Language Therapy Services
Milton Keynes Early Years Speech and Language Therapy Team
Referral form

Back to Milton Keynes Early Years Speech and Language Therapy Team

Referral form

If you’re experiencing difficulties with this form please contact our admin office 01908 725299

Important information

This referral form is for children aged 0-4 years prior to starting school. If your child is over 4 years and attending a school setting (including reception/foundation years) you referral be will declined. Please note referrals for children starting school in September 2022 will not be accepted after 22 July 2022.

Please speak to your child's teacher or SENCO regarding your concerns to discuss if a referral to the school age Speech and Language Therapy Team is required. You can also access information and resources on our website to support your child.

We can only accept referrals for children registered with a Milton Keynes GP.

Referrers name (required if professional)

If you are a professional completing this form, you must have parental consent to continue. Do you have parental consent to make a referral? Required

Radio list field

Yes

No - you cannot complete this form if you tick 'no', please contact and speak with parents to gain their consent

Referrer address (required if professional)

Referrers contact number (required if professional)

Child and Family details

Child's full name Required

Child's DOB Required

Date/time Field

Europe/London

Child's gender Required

Radio list field

Male

Female

Child's full address Required

Child's NHS number - you can find this in your child's red book or by contacting your GP Required

Parent/carer full names Required

Please include second carers address, if different from above

Your relationship to the child Required

Radio list field

Parent(s)

Foster carer(s)

Grandparent(s)

Other

If other, please specify

Who has parental responsibility?

Radio list field

Parent(s)

Foster carer(s)

Grandparent(s)

Other

If other, please specify

Please provide us with at least one mode of contact that we can use to communicate with you and that you consent for us to contact you on.

Child parent's/carers home number

Child parent's/carers mobile number Required

Child parent's/carers email address Required

Preferred method of contact Required

Radio list field

Child parent's/carers home number

Child parent's/carers mobile number

Child parent's/carers email address

Do parents/carers have any information or communication needs that we should consider when providing you with information? E.g. Large print, Easy read, Braille etc. Required

Radio list field

Yes

If yes, please specify

Select your GP surgery. If your GP is not on this list and you'd still like to refer to our team, select `Other`. If you're not registered with a Milton Keynes GP from the list below, your referral will be considered; however not automatically accepted Required

Child's ethnic group Required

If other, please specify

What languages are spoken at home?

Do you require an interpreter?

If yes, please specify which language

Nursery/Pre-School name, address and contact number:

What day's does your child attend nursery/pre-school?

Monday's

Radio list field

All day

Tuesday's

Radio list field

All day

Wednesday's

Radio list field

All day

Thursday's

Radio list field

All day

Friday's

Radio list field

All day

Does your child have an EHC plan? Required

Radio list field

Yes

Does your child have a diagnosis? Required

Radio list field

Yes

If yes, please provide details

Speech and language concerns

Has the child ever had Speech & Language therapy in the past?

Radio list field

Yes

What are the main concerns?

Please indicate the difficulties that the child is having

Attention and listening (e.g. do they turn when you call their name? Can they focus on an activity?)

Radio list field

No concern

Some concern

Significant concern