East Sussex Children's Integrated Therapies referral form

Your information

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You can use this form to refer your child for Speech and Language Therapy, Occupational Therapy, Physiotherapy and Adaptations

Before you start to complete the referral form, please refer to our referral criteria.

In some cases for Speech and Language and Occupational Therapy additional information will need to be uploaded to support a referral as explained below

For speech and language therapy

Please note that if you are making a referral for Eating and drinking, Early Years Language or School Aged Language 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.

For occupational therapy

If you are a school referring a child for motor co-ordination difficulties, please note that you will be required to upload evidence of the child having completed Jump Ahead/Sensory Circuits.
If you are a school referring a child for sensory processing difficulties and/or emotional regulation difficulties please note that you will be required to upload evidence that the child has completed Zones of Regulation sessions.

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. If you are not able to do this it is important that you have met beforehand with the parents or carers and have the answers to these questions to hand.

If you have any questions about making a referral for a child or young person please contact Therapy One Point on 0300 123 2650. Please check our website for opening times.

Please note, all fields marked with an asterisk are mandatory and if not completed the referral will be declined. Thank you.

Start referral here...

Section 1: Key information about the child / young person

Name(Required)

First name Surname

Date of birth(Required)

Gender

Address(Required)

Address line 1 Address line 2 Town/City County Postcode

NHS number

Ethnicity(Required)

Languages spoken by child(Required)

Languages spoken at home(Required)

Is an interpreter required for the parents / carers?(Required)

Yes

Please provide relevant details(Required)

Child's medical diagnosis

Parent(s) name(Required)

Parent’s contact phone number(s)(Required)

Parent’s email(Required)

Does the parent/carer have parental responsibility for this child/young person?(Required)

Yes

Second address

Address line 1 Address line 2 Town/City County Postcode

If not, who holds this (please enter details below including name, relationship to child, contact telephone number and address/email).

Section 2: Referrer

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

Parent/carer

Professional

Section 3: Professional

Name of referrer(Required)

Profession(Required)

Other

Job title(Required)

Agency / organisation(Required)

Address(Required)

Address line 1 Address line 2 Town/City County Postcode

Phone(Required)

Email(Required)

Supporting information

Is the child / young person known to social services?(Required)

Yes

If yes, please tick any that apply

Early Help

LAC

Child in Need

Child Protection

Children’s Disability Team

Please supply name of social worker / Early Help support worker and contact details(Required)

Section 4: Consent

I am...(Required)

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, social care or education professional and have discussed the referral with the person with parental responsibility and they agree 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

Is the person with parent responsibility happy to be contacted by(Required)

Please tick all that apply.

Phone

Text message

Video conferencing

Section 5: GP information

Is GP information the same as the referrer information provided?(Required)

Yes

Name of GP(Required)

If not known please write “not known”

Surgery(Required)

Phone(Required)

Section 6: Early years / school information

Is the early years/school setting the referrer?(Required)

Yes

Is the child / young person attending nursery / pre-school / school?(Required)

Yes

Name of nursery / pre-school / school attended(Required)

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

Yes

If yes, please name

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

School/nursery email(Required)

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(Required)

Address line 1 Address line 2 Town/City County Postcode

Section 7: Other professionals involved

Are any other professionals involved?(Required)

Yes

Other professionals involved

Agency

Name and role

Phone

Section 8: Services required

Please indicate the support required to meet the needs of the child / young person(Required)

Please tick all applicable. Eating and drinking is part of Children's speech and language therapy.

Children’s speech and language therapy

Children’s occupational therapy

Children’s physiotherapy

Children's adaptations

Section 8: Children's speech and language therapy

Children's SLT - please tick from the following(Required)

Please speak to one of our speech and language therapists on 0300 123 2650 before referring a school-age child because of difficulties with speech sounds or language.

Early years language

School aged language

Early years speech sounds

School aged speech sounds

Stammering

Selective mutism

Feeding/eating/drinking/swallowing

Other

Please describe your concerns

Early years language

What age group in months does your child fit into?(Required)

12-23 months: Please tick all that are applicable to the child:

Limited or no babbling

Not responding to speech and / or sounds

Minimal or no attempts to communicate

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

Only able to focus on activities of their own choice

Other (please describe below)

Other, please specify

23-35 months: Please tick all that are applicable to the child:

Other, please specify

36-47 months: Please tick all that are applicable to the child:

Minimal or no attempts to communicate

Not putting more than two words together

Limited or no use of verbs (action words)

Not understanding simple instructions

Using jargon with real words in between (‘jargon’ means streams of sounds which sound almost like words but aren’t)

Child is frustrated with their difficulty communicating

Difficulty with focusing on activities that they haven’t chosen, or difficulty moving their attention from one activity to another

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

Other (please describe below)

Other, please specify

48 months + (not at school): Please tick all that are applicable to the child:

Minimal or no attempts to communicate

Using single words or very short sentences only

Not understanding simple instructions and questions

Using jargon with real words in between (‘jargon’ means streams of sounds which sound almost like words but aren’t)

Child is frustrated with their difficulty communicating

Difficulty with focusing on activities that they haven’t chosen, or difficulty moving their attention from one activity to another

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

Other (please describe below)

Other, please specify

Please describe the impact of the above the child

School age language

Has a Language Link Assessment been completed?

Schools are expected to complete a Language link assessment.

Yes

Don't know

Have you completed the Language link intervention?

Yes

Don't know

Please see Section 9 to upload the relevant documents.

Does your concern relate to:

General understanding of language

General use of language

Grammar

Vocabulary

Memory

Attention and listening

Narrative

Please provide details about your concerns regarding language

Early years speech sounds

Are there difficulties with specific sounds?

Yes

What specific sounds have you noticed are difficult?

Have you noticed any of the following patterns?

Leaving the final sounds off words, for example ca instead of cat, dre instead of dress and par instead of park

Replacing long sounds (like s and f) with short sounds (like t and b), e.g. sock = tock, four = bour

Replacing back sounds (like k and g) with front sounds (like t and d), e.g. key = tee, gate = date

Reducing the number of syllables in a word, for example elephant = efent

Please ask your child to try and say the words listed in the table below and record how they say them back to you:

School age speech sounds

Have you completed the Speech link assessment?

Schools are expected to complete a Speech link assessment and one term of intervention prior to referral.

Yes

Don't know

Have you completed the Speech link intervention?

Schools are expected to complete a Speech link assessment and one term of intervention prior to referral.

Yes

Don't know

Please see Section 9 to upload the relevant documents.

Are there difficulties with specific sounds?

Yes

What sounds are difficult?

Stammering

Age bands

3-7 years

7-11 years

11-19 years

3-7 years - Are you concerned that:

Your child stretches words e.g. mmmmmmummy

Your child repeats initial sounds e.g. m-m-m-mummy, or part of the word e.g. mum-mum-mum mummy

Spoken communication is disrupted

Your child is showing frustration or concern about their talking

7 -11 years - Are you concerned that:

Your child stretches words e.g. mmmmmmummy

Your child repeats initial sounds e.g. m-m-m-mummy, or part of the word e.g. mum-mum-mum mummy

Spoken communication is disrupted

Your child is showing frustration or concern about their talking

Did your family see a speech and language therapist when your child was younger for support with stammering?

Yes

11-19 years - Are you concerned that:

Your child repeats initial sounds e.g. m-m-m-mummy, or part of the word e.g. mum-mum-mum mummy

Spoken communication is disrupted

Your child is showing frustration, anxiety or concern about their talking

The stammer has recently changed in frequency or severity

Your child has asked to see someone to help them with their speech

Did your family see a speech and language therapist when your child was in Primary school to support stammering?

Yes

Has your child had intervention from a speech and language therapist over a year ago?

Yes

Can you please give us information on what you child's speech sounds like?

Selective mutism

Is there a pattern of talking and not talking with people and/or situations? Please give details

Has this been evident for more than 2 months in a new setting? Please give details

Does the child ever show signs of anxiety in speaking situations, for example appearing 'frozen' and/or avoiding eye contact? Please give details

Feeding/eating/drinking/swallowing

Does your child have difficulties drinking?

Yes

Does your child have difficulties eating?

Yes

Please give a brief description of your concerns regarding your child’s eating and drinking skills

Please tick any of the following if you have seen them in your child

If the only sign is vomiting, weight loss or gagging, please contact TOP on 0300 123 2650 for further advice.

Please give a brief list of what your child eats/drinks

Does your child have a history of reflux?

Yes

Please list medications here

Are there any sensory issues or challenging behaviour around mealtimes?

Yes

If yes, please describe

Interventions that have already been completed

Language link/speech link

Selective Mutism workshop

Toddler Talk (with Early Communication Support Workers)

Thrive

Nurture groups

Lego therapy

Colourful semantics

Elklan

Other

Please describe any other interventions that have been completed

What has been helpful

Section 8: Children’s physiotherapy

What are your main concerns about the child/young person and how do these concerns impact the child/young person’s daily life?

Please let us know what support/interventions are in place currently?

Has the child ever received any previous input? If yes what was it and did it help or not?

Section 8: Children’s occupational therapy

What are your concerns regarding the child’s functional difficulties?

Does the child have any physical movement difficulties?

Does the child/young person have motor co-ordination difficulties which severely affect functional daily living?(Required)

Yes

Please select who is completing this referral(Required)

Parent/carer or Healthcare professional

School/teaching staff

Does the child attend primary school?(Required)

Yes

For primary age school children we will only consider referrals if Jump Ahead/Sensory Circuits has been completed a minimum of three times a week for four academic terms so please attach evidence paperwork as appropriate.(Required)

Without this evidence your referral will be declined.

Drop files here or

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

Please detail main concerns(Required)

Has the child attended at least four terms of Jump Ahead and/or sensory circuits?

Yes

Please detail the main concerns(Required)

Has the child attended either Jump Ahead or Sensory Circuits?(Required)

Yes

When did the sessions commence?(Required)

Who delivered these sessions?(Required)

How many sessions have been delivered?(Required)

Do you have any concerns about the child’s behaviour?

Does the child have any sensory difficulties impacting on their function?

If yes then we require evidence of three functional difficulties caused by sensory difficulties in order for this referral to meet the CITES service criteria.

Dressing and undressing, including fastenings

Finds difficult

Can do with support

Can do well

Cleaning teeth

Finds difficult

Can do with support

Can do well

Washing and drying face, hands and body

Finds difficult

Can do with support

Can do well

Using cutlery

Finds difficult

Can do with support

Can do well

Going to the toilet

Finds difficult

Can do with support

Can do well

Drawing and writing

Finds difficult

Can do with support

Can do well

Balance including jumping and hopping

Finds difficult

Can do with support

Can do well

Ball skills including throwing and catching

Finds difficult

Can do with support

Can do well

Focus and attention

Finds difficult

Can do with support

Can do well

Organisation

Finds difficult

Can do with support

Can do well

Emotional regulation

Finds difficult

Can do with support

Can do well

Is there any existing support in place, for example, move n sit cushion, writing slope, adaptive cutlery, sensory strategies?

Yes

Has the child attended zones of regulation?

Yes

If yes, please provide details

Please upload evidence

Drop files here or

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

In order to meet service criteria we require evidence of at least four terms of attendance of one of these programmes

Drop files here or

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

Section 8: Adaptations

Please advise what type of property the child/young person lives in?

House

Flat

Bungalow

Other

Other, please specify

Is the property

Privately owned

Privately rented

Rented through Housing Association

Local Authority Housing

If it’s Housing Association or Local Authority Housing who owns the property?

How many occupants live in the property and what are their ages and relationship to child/young person?

Does the child/young person have any physical mobility difficulties? Do they use a wheelchair, walking aid or hoists to support their mobility?

Does the child/young person have any sensory difficulties that affect their ability to complete daily tasks? Please provide details

For example, brushing teeth or hair/using a bath or shower/dressing or undressing/managing toileting.

Has the child/young person had support from CAMHS – Child & Adolescent Mental Health Service or FISS – Family Intensive Support Service or Positive Behavioural Support Team (PBS Children's Services)?

Referrer to provide details.

Do you have concerns that any behaviours associated to the child/young person’s medical condition affect their own safety or those of others?

Dressing and undressing, including fastenings

Finds difficult

Can do with support

Can do well

Cleaning teeth

Finds difficult

Can do with support

Can do well

Washing and drying face, hands and body

Finds difficult

Can do with support

Can do well

Using cutlery

Finds difficult

Can do with support

Can do well

Going to the toilet

Finds difficult

Can do with support

Can do well

How does the child/young person get in and out of the home?

What rooms are on what floor?

Where does the child/young person currently sleep?

Is there a garden? If yes how is it accessed?

How is the house laid out in terms of the number and location of bedrooms, location of bathrooms and location of kitchen?

How is the physical home environment impacting on the child's daily life?

How is the physical home environment impacting on the care they receive?

Any further information you feel may be relevant

For example, other occupants who have medical conditions.

Does the child/young person have a Blue Badge?

Yes

Is the child/young person in receipt of any benefits?

Yes

Please provide details of any benefits the child/ young person is receiving

Section 8: continued

How are you hoping we can help?

Support already in place

Education Health Care Plan (EHCP)

Additional Needs Plan (ANP)

Personalised and Targeted Plan

Other

Other, please specify

Are there any other concerns or conditions we should know about

Social Emotional Mental Health (SEMH)

Social Communication

English Additional Language (EAL)

Autistic Spectrum Disorder (ASD)

Attention Deficit Hyperactivity Disorder (ADHD)

Hearing Loss

Visual Impairment

Other

Other, please specify

Please give any information which hasn’t been covered so far

Section 9: Document upload

Documents

Please upload mandatory information.

Occupational Therapy

Zones of regulation record sheets – mandatory for schools referring in for sensory processing difficulties and/or emotional regulation difficulties

Speech and Language Therapy

Speech link assessment and intervention – mandatory for schools referring in for speech sound referrals
Language link assessment and intervention – mandatory for schools referring in for language referrals

Please upload additional information

If you have any of the following non-mandatory documents, please upload them.

Schedule of Growing Skills (SOGS) or Ages and Stages Questionnaire (ASQ)
Language checker
Paediatricians report
Other Information which you wish to include, for example, supporting photographs of presenting complaint.

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.

Recommended

Services

Pages

Leaflets

East Sussex Children’s Integrated Therapies referral form

Your information

Section 1: Key information about the child / young person

Section 2: Referrer

Section 3: Professional

Section 4: Consent

Section 5: GP information

Section 6: Early years / school information

Section 7: Other professionals involved

Section 8: Services required

Section 8: Children's speech and language therapy

Section 8: Children’s physiotherapy

Section 8: Children’s occupational therapy

Section 8: Adaptations

Section 8: continued

Section 9: Document upload