SLT Referral Form

Please use the form below to refer a patient to the Speech and Language Therapy service.

PLEASE NOTE:

Is the person experiencing regurgitation of food/drink? Or the sensation of food getting stuck below the level of the throat after swallowing?

If so please DO NOT complete this form, but refer to Gastroenterology.

​PLEASE COMPLETE ALL RELEVANT SECTIONS (incomplete referrals will not be accepted)

All fields marked * are required:

PATIENT DETAILS:

Address:



 
 




 

MEDICAL BACKGROUND:

TYPE OF REFERRAL:

*I am referring this patient for:

SWALLOWING:

Reason for Referral:
Loss of weight in last 3-6 months? YesNo
New episode coughing/choking on drinks? YesNo
New episode coughing/choking on food? YesNo
Has it:
Deterioration of pre-existing swallowing difficulties? YesNo
Have there been recurrent chest infections? YesNo
Difficulty swallowing saliva? YesNo

COMMUNICATION:

Is this a new problem? YesNo
Is the problem getting worse? YesNo
Please indicate if you have concerns regarding the following:
Understanding spoken language: YesNo
Speaking and getting the right words out: YesNo
Reading/writing: YesNo
Slurred speech: YesNo
Stammer: YesNo
Voice Problem: YesNo
Please rate the person's ability to communicate in social or work situations:
0 (No difficulty)12345678910 (Severe difficulty)
Please note: the management of the patient's nutrition, hydration and communication remains the responsibility of the GP or Extensive Care Team until the patient has been seen by the Speech and Language Therapy Service. It is essential that you inform us of any changes to the patient's condition whilst the patient is awaiting assessment.

REFERRER DETAILS:

 
 
Contact Address:



 
 
 
*Has the person consented to this referral being made? YesNo

RISKS:

Are you aware of any potential risks to our staff from the person, their home or other members of the person’s household? YesNo