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.

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

Child and Family details

Required
Required
Child's gender Required
Required
Required
Required
Your relationship to the child Required
Who has parental responsibility?

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.

Required
Required
Preferred method of contact Required
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
Required
Required

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

Monday's
Tuesday's
Wednesday's
Thursday's
Friday's
Does your child have an EHC plan? Required
Does your child have a diagnosis? Required

Speech and language concerns

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

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?)
Required
Understanding spoken language (e.g. can they follow instructions?)
Required
Communication (e.g. how do they let you know what they want?)
Required
Speech sound/voice
Required
Social interaction and play (e.g. do they play with other children? Do they look at you when you speak to them? How do they play with toys?)
Required
Stammering
Required
Eating, drinking and swallowing
Required

Consent

By accessing Speech and Language Therapy Services, parents/carers accept that information regarding their child will be shared with all other health, education and care providers involved in your child’s care. This is the policy of the Speech and Language Therapy Service and is national best practice in the interest of the child. Electronic patient records are kept on a shared system, called Systmone, with all other community healthcare services, including the GP.

Do you consent to your child being assessed by a Speech & Language Therapist? Required
It is best practice to share information (e.g. reports and therapy targets) with your child’s nursery/pre-school/Childminder and any other Education professional involved in your child’s care. Do you consent to this? Required
For some appointments we will send you a text message reminder. Do you consent to receiving text message reminders? Required
Required
Required