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