Children’s Therapies referral

Your information

If you would like to find out what happens to personal information held about you, please read the your personal information section on our privacy policy page for more information.

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Step 1 of 11

You can use this form to refer to Speech and Language Therapy, Occupational Therapy and Physiotherapy.

Referrals to Occupational Therapy and Physiotherapy can only be made by a health, education or social care professional. We are unable to accept parental/carer referrals.

Please note you are not able to refer for a social communication assessment using this referral system.

You can also refer to Children’s Care Coordination team.

Referral criteria updated as of 5 September 2022, please see the most recent referral criteria.

Before you start to complete the form please note that if you are making a referral for Eating and drinking, Early Years Language or School Aged Language or Selective Mutism you will need to have completed and saved the relevant referral resources on your own system, ready to upload at the end of this referral form.

Once you have started to fill in the 'referral form' you will be unable to save it until you have completed it. Please give yourself enough time to complete the form (approx. 20 minutes) and remember to attach the requested referral resources. Referrals risk being rejected if they do not include all information requested.

If you are a health or education professional we recommend completing this form with the child’s parent or carer present as there are questions that require their knowledge of the child. Please make parents/carers aware of Kent Community Health Foundation Trust’s Communication Policy – privacy policy. For communication preferences and opt out option please see referral form.

If you have any questions about making a referral for children and young people please find your local team.

Start referral here...

Please indicate the support required to meet the needs of the child / young person*

Please tick all applicable.

For more information on each team please see:

Occupational therapy
Physiotherapy
Speech and language therapy
Care coordination

Children’s speech and language therapy

Children’s occupational therapy

Children’s physiotherapy

Feeding and swallowing

Care Coordination

Referrals can not be accepted from parents/carer. If you are a parent/carer wanting to make a referral please speak to your child’s nursery/school or a member of their medical team to complete the referral with you.

Section 1: Key information about the child / young person

Hidden

OLD Name

First name Surname

First name*

Surname*

Date of birth*

Gender

Address*

Address line 1 Address line 2 Town/City County Postcode

Please select area*

If your area is not listed here please contact your nearest Children’s Therapies base before completing the form.

Please note: We are unable to accept referrals for children in Ashford, Dover, Deal and Shepway. If you are unsure please call the team to check - Children's Therapies.

NHS number

Ethnicity*

Languages spoken by child*

Languages spoken at home*

What language would you like the assessment to be in?*

Section 2: Referrer information

Name of referrer*

Job title / relationship to child*

Are you making this referral as the child’s parent or carer or as a professional?*

Parent/carer

Professional

Agency / organisation*

Is your address the same as the childs?*

Yes

Address*

Address line 1 Address line 2 Town/City County Postcode

Phone*

Email*

Supporting information

Is the child / young person known to social services?*

Yes

If yes, please tick any that apply

Early Help

LAC

Child in Need

Child Protection

Disabled Children’s Team

Has the child ever been a Looked After Child?*

Yes

When were they a looked after child?*

Please provide dates.

Any further information?

Please supply name of social worker / Early Help support worker and contact details*

Hidden

OLD Is an interpreter required for the parents / carers?

Yes

Hidden

OLD Please provide relevant details*

Section 3: Parent / carer information

Is parent / carer information the same as referrer information provided?*

Yes

Name of parent / carer*

Relationship to child*

Second address

If different from address given for child in section 1.

Address line 1 Address line 2 Town County Postcode

Phone*

Alternative phone

Preferred method of contact (please tick all relevant)*

Text

Phone

Post

We may send appointment letters, reports and appointment text reminders via email or text messages unless you opt out

Consent to receiving communications

Opt out

Please remember to check your junk/spam mailbox. For further information please read our privacy policy.

Does this person have parental responsibility?*

Yes

If no, who has parental responsibility? Please provide, name, address, phone, email and your relationship to child.*

Does anyone else have parental responsibility*

Yes

If yes, who else has parental responsibility? Please provide, name, address, phone, email and their relationship to child.*

Are one or more of the child’s parents or carers currently working in the armed forces?*

Yes

Section 4: Consent

I am...*

the person with parental responsibility who agrees to this referral being made to Kent Community Health NHS Foundation Trust and understands that this referral will be discussed by the relevant service or services

a health or education professional and have discussed the referral with all parties who have parental responsibility and they have agreed to this referral being made to Kent Community Health NHS Foundation Trust and understand that this referral will be discussed by the relevant service or services

the person with parental responsibility who consents to receiving appointments, documents and notifications via email and text message

Section 5: GP information

Is GP information the same as the referrer information provided?*

Yes

Name of GP*

If not known please write “not known”

Surgery*

Phone*

Section 6: Early years / school information

Is the child / young person attending nursery / pre-school / school?*

Yes

Name of nursery / pre-school / school attended*

Will the child’s nursery / school change at the start of the academic year (September)?

Yes

If yes, please name

Are the details for the key contact person at the school / nursery / pre-school the same as the referrer details?*

Yes

Who is the key person for us to contact at the school / nursery / pre-school?*

School/nursery email*

Please only use work email addresses for the school/nursery. If you do not know the email address write “not known”.

School/nursery phone

Address*

Address line 1 Address line 2 Town/City County Postcode

Section 7: Other professionals involved

Other professionals involved

Agency

Name and role

Phone

Section 8: Services required

Children's SLT - please tick from the following*

Early years language

Speech sounds

School aged language

Stammering

Selective mutism

Other

Please see the pages for more information on the following:

Early language and communication
Speech sounds
School aged language
Stammering
Selective mutism
Feeding and swallowing

Have you completed the speech screen/school years speech link?*

Yes

If yes, please tick any of the following...

Speech link attached

Limited range of sounds (e.g. only uses ‘d’)

Vowels are wrong (e.g. ‘bee’  ‘bar’)

Says ‘t’ and ‘d’ as ‘k’ and ‘g’ (e.g. ‘tea’  ‘key’)

Uses unusual sounds that are not typically heard in the English language

Child talks through their nose

Misses off the beginning (e.g. ‘pig’  ‘ig’) or middle (e.g. ‘teddy’ becomes ‘te-y’) of words

Has very few sounds and inconsistent, different productions of the same words

‘s’ is produced between the teeth (‘bus’  ‘buth’) or sounds slushy (please only select this for children aged at least 7years)

Other

Other, please specify

If not, please complete the speech screen/school years link.

What are you hoping will be the outcome for the child / young person as a result of this referral?*

What age group does your child fit into?*

1-2 years: Please tick all that are applicable to the child:

No babbling

Not responding to speech &/or sounds

Minimal/no attempts to communicate

Family history of language/literacy problems

Parent/professional concern

Lack of progress in language/Early Years Foundation stage despite targeted support

Other (please describe below)

2-3 years: Please tick all that are applicable to the child:

No communicative intent

No words and/or failure to combine words at 2 years

No /limited verbs

Minimal reaction to spoken of language

Regression or stalling of language development

Family history of language/literacy problems

Parent/professional concern

Lack of progress in language/Early Years Foundation Stage despite targeted support

Late talkers

Poor language comprehension

Other (please describe below)

3-4 years: Please tick all that are applicable to the child:

Using 2-word utterances at most

No /limited verbs

Not understanding simple instructions

Largely unintelligible to close relatives

Child is frustrated by limited communication ability

Poor sentence repetition -can child copy adult model at the child’s level of language

Family history of language/literacy problems

Parent/professional concern

Lack of progress in language/Early Years Foundation stage despite targeted support

Late talkers

Poor language comprehension

Other (please describe below)

4-5 years (not at school): Please tick all that are applicable to the child:

Severe difficulties likely to be persistent

Using 3-word utterances at most

No /limited verbs

Poor sentence repetition - can child copy adult model at the child’s level of language

Difficulties understanding spoken language or late talkers with poor language comprehension

Largely unintelligible to strangers

Family history of language/literacy problems

Parent/professional concern

Lack of progress in language/EYFS despite targeted support

Child is frustrated by limited communication ability

Other (please describe below)

Please describe the impact of the above the child

Support already in place*

Early Help

LIFT (Local Inclusion Forum Team)

EHCP (Education Health and Care Plan)

SENIF (Special Educational Needs Inclusion Fund) or Higher Needs Funding

STLS (Specialist Teaching and Learning Services)

Personalised or targeted plan

Unsure as options

No support in place

Other support in place

If Early Help, please provide name and contact details

Please state any interventions in place

Movement programme - BEAM / Sensory circuits / Fizzy / Clever hands

Language link / Speech link

Selective mutism strategies from workshop

Early Years Targeted Plan

No of sessions delivered*

Please upload the summary*

Accepted file types: pdf, docx, jpg, jpeg, png, xlsx, pptx, Max. file size: 50 MB.

Date of workshop attended*

DD slash MM slash YYYY

Section 9: Information from the parent or carer

Does your child have difficulties with speech and language (talking, understanding, etc)?

Yes

If yes, please give examples of your concerns*

Does your child have physical difficulties (movement, coordination, etc)?

Yes

If yes, please give examples of your concerns

Please give examples of how these concerns impact on your child’s everyday life*

Without this information we are unable to progress your referral.

Does your child speak more than one language, or is more than one language used in your family home?*

Yes

If yes, please specify languages

If yes, would you like to have an interpreter at appointments

Were there any pregnancy or birth complications, including postnatal depression?*

Yes

If yes, please give details

Please describe your child’s personality

At what age did your child...

If referring for early years services (SLT, PT,OT) please complete the following, or if for School years and not relevant please just leave empty or add n/a.

Roll

Sit

Walk

Say their first words

Become toilet trained

What does your child like to play with?

Do you have any concerns about your child’s behaviour?*

Yes

If yes, please give details

Does your child have any of the following health problems?

Ear infections / colds / asthma

Allergies

Medications

Other (please specify)

Other, please specify

Please give details and approximate dates of any illnesses, hospitalisations or serious accidents

Section 10: Document upload

If you are referring for the following support, you must upload the relevant supporting form*

Eating and drinking referral form

School Years Speech and Language (early years)

School Years Speech and Language (school years)

Occupational Therapy - Fizzy / Beam Records

Not applicable

If you do not attach the relevant documents we may have to reject your referral – please check that you any relevant documents are uploaded.

Please upload any other relevant documents you have permission to share*

Please note, if the relevant documents are not uploaded we will not be able to progress your referral.

Please do not upload password protected documents.

Drop files here or

Accepted file types: pdf, docx, jpg, jpeg, png, xlsx, pptx, Max. file size: 20 MB.

Once submitted to Kent Community Health NHS Foundation Trust, the referral will be discussed with the relevant service(s) and the outcome will be shared with the referrer and parent / carer.