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Referral FormNuffield Paediatric Speech Disorders ClinicIntroduction The Nuffield Paediatric Speech Disorders clinic provides specialist assessment ofspeech for children with severe or persisting speech sound disorders, which are notfelt to be due to another condition. We do not provide assessment of language disorder or ASD/autism. This form should be completed by a qualified speech and language therapist. Referrals must include all relevant documentation, as detailed in this form. Thisincludes specific details of the child’s speech and language skills, as well as relevantmedical and educational information. Reports should be attached where appropriate. A supporting letter and a medical summary from the child’s GP must also be included. Referrals received without the necessary information will be returned to the referrer.Referral CriteriaChildren must: Be between 3 and 18 years of age. Be able to participate in formal assessment, involving naming pictures andimitating sounds. Have had at least one block of therapy targeting their speech. Have verbal comprehension skills at a 3 year level on formal assessment, or athree information carrying word level. Have at least 30 spoken words, used regularly and spontaneously. Have had an audiogram in the last 3 months. Have had some assessment of their learning skills e.g. developmental assessment,educational psychology assessment or information/ report from school/nursery staff.The results of this assessment must be discussed with parents/carers prior toreferral.

ChildName: .DOB: .Children must be at least 3years old when referred.Address: .Parent / carer: .Telephone: .Email: .Please check that the parent/carer is happy for us tocontact them by email.Has the parent / carer given consent for us to make contactin this way?YesNoReferring SLTOrganisation: .Name: .Address: .We will contact local SLTs byemail following the clinic.Please make sure we haveappropriate email addresses.Telephone: .Email: .Other SLT involved with childOrganisation: .Name: .Address: .Telephone: .If there is another SLTinvolved with the child, pleasegive details here.Where possible we needdetails of the local NHS SLT.Email: .GPName: .Address: .Telephone: .SchoolName: .Type of provision / school (please select)Mainstream, speech / language resource, special school,other: .Senco: .Address: .Telephone: .Email: .We require a letter fromthe child’s GP supportingthe referral, in order tosecure funding.

Reason for referralPlease attach GP print offsummary plus relevant medicalreports eg. from Paediatricianor Neurologist.Please selectDiagnosisTherapy adviceTherapyOngoing liaison with local therapy servicePlease ensure that familiesunderstand that we will not beable to diagnosedevelopmental verbaldyspraxia (DVD) in all cases,e.g. in children with verylimited verbal language or withcomplex needs. However, weare happy to provide advice onmanagement. Limited therapymay be offered at this centre toexplore therapy targets andsupport local provision.Additional comments:Information RequiredMedical findingRelevant diagnoses: .Hearing statusPlease attach a recentDoes s/he have a hearing loss?YesNoaudiogram (last 3Does s/he have a history of hearing loss?YesNomonths).Does the child have learning difficulties?YesNoDoes s/he have an education health andcare plan (EHCP)?YesNoDoes s/he have additional support in school? YesNoEducation Information.Motor skillsDoes s/he have gross motor difficulties? YesNoDoes s/he have fine motor difficulties?NoYes.Please attach any currenteducation, health and careplans (EHCP), and individualeducation plan (IEP) and otherrelevant reportsWhere learning difficulties aresuspected, these should beinvestigated before referringto the speech clinic.Please attach Occupationaland/or Physiotherapy reports ifappropriate.

Communication SkillsDoes s/he have a diagnosis of autism spectrum disorder?YesNoWhat is his/her preferred means of communication?Please select: SpeechSignOther: .Ability to participate in Assessment & TherapyIs s/he able to participate in formal assessment? YesNo.Where there are concerns aboutsocial communication, theseshould be investigated beforereferring to the speech clinic.Children need to be able toparticipate in adult directednaming and imitation activitiesfor at least 30 minutes.If you are concerned that thechild may not speak in clinic,due to shyness, please contactus by emailing us tive DevelopmentPlease s:Reports attached: (please riate

Verbal ComprehensionPlease fficultiesNumber of information carrying words: (please circle)1 2Ageappropriate34 moreVocabularyDetails / recent formal assessment scores (no more than 3 months old)Reports attached: (please list)

Expressive LanguagePlease select the options that best describe the child’s current ifficultiesAgeappropriatePlease indicate which mode(s) of communication the child uses and rank eg ‘1’ for primary modeSpeechPointing, bodylanguageOwn signs /GestureSigningPicturebook/boardVoiceoutput aidVocabulary size (words used regularly and spontaneously)0-1010-2030-50100 Ageappropriate200 Typical number of words spoken in a sentence:Single wordSeries of singlewords2 words2-4 words5 wordsTypical number of elelments (spoken words / signs / gesture) in a sentence:Single elementSeries of singleelements2 elements2-4 elements5 elementsPronounsConnectivesWord endingsSentence structure: Does s/he use:Appropriateword orderAuxiliariesDetails / recent formal assessment scores: (no more than 3 months old)Examples of typical utterancesReports attached (please list)

SpeechTherapyHow many sessions of direct therapy on speech to date? .Over what period?.Frequency of direct therapy? .Frequency of practice? .Who is practising with the child?.Current speech targetsProgressSounds in isolationSounds in words / patterns and processesIntelligibility in conversational speechDetails / formal assessment findings / scoresReports attached (please list)

Signed: .Date:DD / MM / YYYYSpeech & Language Therapist: .Where all the relevantinformation is not included, thereferral will be returned to you.Please check that all of the following areincluded or attached to this form:Case history formGP letter supporting referralGP print off summaryMedical reports, if appropriatePlease check the appointmentdate with the family if you areintending to come to the clinic.Be aware that appointmentsare sometimes changed.Paediatric report, if appropriateEducational Psychology report,if appropriateSLT report(s)Contact details for SLT (including email)Contact details for SLT manager (including email)Please post the referral pack to:Ms Shula BurrowsConsultant Speech and Language TherapistNuffield Paediatric Speech Disorders TeamRoyal National ENT Hospital Admin BaseGround Floor North250 Euston RoadLondon, NW1 2PGWe will contact the referringSLT after the appointment togive feedback, by email.Please note that, for accepted referrals, appointments will beheld at: Nuffield Paediatric Speech Disorders Clinic, RoyalNational ENT and Eastman Dental Hospital, 47-49 HuntleyStreet, London, WC1E 6DGOr email (via secure email only i.e. nhs.net to nhs.net) act DetailsWe will notify the referring SLT and parent/carer: When the referral is accepted/rejected To make an appointment (parent only)If you need to get in touch with us, please e regret that we are unable todiscuss referrals. We hope thatthe information in this formand the referral guidelines willanswer any queries.

Nuffield Paediatric Speech Disorders Team Royal National ENT Hospital Admin Base Ground Floor North 250 Euston Road London, NW1 2PG Please note that, for accepted referrals, appointments will be held at: Nuffield Paediatric Speech Disorders Clinic, Royal National ENT and Eastman Dental Hospital, 47-49 Huntley Street, London, WC1E 6DG