Children's therapy service referral form :: Lincolnshire Children's Therapy Services

Children’s Therapy Services – request for help

Name of child: Required

Child's date of birth: Required

Child's NHS No:

Address: Required

Address Line 1

Address Line 2

City

County

Country

Postcode

Telephone No: Required

Parent/carer/guardian name Required

Parent/carer email address Required

Name of second parent with parental responsibility Required

Contact details for second parent with parental responsibility Required

Please state your child's religion or belief. Required

Do you require an interpreter? Required

Yes

Name of pre-school/school setting

Pre-school/school email address:

Name of referrer: Required

Please state your relationship with the child.

Please tick this box if you are a professional:

If you are a professional, please provide your email address:

Is the child currently known to Children's Social Care and/or does they have an allocated Social Worker? Required

If yes, please provide Social Worker's name and contact details:

Referral to Speech and Language Therapy

Swallowing: My child shows signs of struggle (coughing, spluttering, eyes watering etc.) when they are swallowing food or liquid.

Functional communication: My child doesn’t have an effective way to communicate what they want with me, (e.g. words, symbols or signs). OR my child copies language that they hear but isn’t able to ask me for things they want or need.

Understanding of language: My child finds it tricky to understand instructions that I give them.

Use of spoken language: My child is able to use words, but they are not yet joining these together or their sentences appear jumbled.

Speech sounds: I struggle to understand the words my child is saying.

Stammering: My child is repeating sounds and/or words, stretching sounds out, or the words are getting stuck.

Selective mutism- my child speaks freely in some places, with some people but doesn’t speak freely in other consistent circumstances e.g they talk with family at home but not at nursery. This is not related to speech sounds or being understood.

Voice: When my child talks their voice sounds croaky/rough, sounds too high or too low, or they lose their voice completely.

Referral to Physiotherapy:

Physiotherapy

Referral to Occupational Therapy:

Occupational Therapy

Occupational Therapy telephone advice line

For Physiotherapy and Occupational Therapy referrals, please describe your concerns:

Please share any details on your child’s diagnosis, medical problems or health needs.

By requesting this referral to the LCHS Child Therapy Services the parent/carer gives verbal/written consent to the Child Therapy Service sharing relevant information, including electronic records, with other services or professionals involved with the child. We use online services to support our referral and triaging processes. We are currently using Isla Care. By submitting this referral, you are consenting to us utilising this platform to gather more information from you about your child’s needs.

Do/do not consent to:

Share in with other care services – this means that other services, such as GP, health visitor and educational setting, are able to share information pertinent to your child’s therapy needs with us. Required

Yes

Share out with other care services – this means that we are able to share pertinent information relating to your child’s therapy support with other services, such as GP, health visitor and educational setting. Required

Yes

I agree to the privacy policy.

Children's therapy service referral form

Children’s Therapy Services – request for help

Do/do not consent to:

Accessibility tools