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Referral form

Speech and language therapy - Adult

Are you requesting assessment of: * required



Part 1
Patient details
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(By giving us your mobile number you consent to receiving SMS reminders of appointments. If you wish to opt out at any time please contact us.)
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(please provides dates of diagnosis/onset of illness if known)
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To what degree does the patient exhibit the following:
Recent deterioration in general health: * required




Difficulty maintaining seated posture: * required




Pain: * required




Fatigue: * required




Drowsiness: * required




Distractability/reduced concentration * required




Challenging behaviours: * required





(e.g.: two person visits, which direction to approach the patient, etc.)
Mental capacity and consent to referral
Does patient have capacity to consent to referral to SLT? * required


Patient aware of, and agrees to, referral to SLT: * required


If NO to above is referral being made in patient’s best interests?: * required


Any previous capacity assessments or best interests decisions?: * required


Referrer
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Part 2
Swallowing difficulty

Please indicate to what degree that patient exhibits the following:

Difficulty maintaining oral hygiene:




Respiratory difficulties, including chest infections:




Difficulty eating/drinking independently/unaided:




Unintentional/unexplained weight loss:




Distress as a result of swallowing difficulty:




Please indicate what type of food the patient is having at the moment:






Please indicate what type of drink the patient is having at the moment:







Is this swallowing difficulty:


Is this swallowing difficulty:




Part 3
Communication difficulty

Please indicate to what degree the patient exhibits the following:

Difficulty understanding spoken language:




Difficulty using spoken language:




Difficulty understanding written language:




Difficulty using written language:




Slurred speech:




Voice changes (e.g.: husky, croaky, strained):




Stammering/non-fluent speech:




Quiet voice/reduced volume:




Distress as a result of communication difficulty:





Is this communication difficulty:


Is this communication difficulty:




You will see a thank you page once the form has been submitted. If you do not see this page then you have overlooked to complete some of the required fields. Please check the form, complete the missing details and resubmit. Thank you.

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