Speech & Language Therapy Parental Consent and Home Information Form

Speech & Language Therapy Parental Consent and Home Information Form
Sarah Dunne - Speech and Language Therapist provides in-school speech & language therapy (SLT) for children at Broom Barns School. Your child has been prioritised to be seen for SLT intervention. Please complete the form below to provide your consent and information regarding your child.
Name of child*

First NameLast Name
Date of birth of child*

DayMonthYear
Date
My child may be seen for speech and language therapy in school *
Sarah Dunne may liaise with other professionals to share information about my child’s speech & language development *
Sarah Dunne may liaise with other professionals to share information about my child’s speech & language development *
Reports and targets that are shared with school/parents, may be shared withother professionals (as required) *
I understand that Sarah Dunne will keep secure records about my child. (Privacy Notice available on request) and that I may be contacted to discuss my child’s speech and language development.
Name of Parent

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email of Parent*
example@example.com
Speech and language development:
What are your concerns about your child’s speech and language development?*
How does your child communicate with you at home?*
Do you have any concerns about your child’s understanding of language? Can he/she follow instructions or respond to questions?*
How does your child play and interact with other children?*
Developmental History:
Were there any significant complications during your pregnancy or your child’sbirth?*
Did your child have any difficulties feeding as a baby? Do they have any difficulties with feeding now?*
How old was your child when they started to sit (without support)*
How old was your child when they started to crawl*
How old was your child when they started to walk*
How old was your child when they started to babble (e.g. bababa/dadada)*
How old was your child when they started to point at objects or people?*
How old was your child when they started to say their first words?*
How old was your child when they started to put two words together?*
Home Information:
Does your child have any brothers or sisters? what are their ages? *
What languages are spoken at home? Please provide details, including whatlanguages your child understands and uses at home.*
In your family, is there any history of: Speech, language or communication needs?Learning difficulties? Hearing difficulties?*
Background Information
Does your child have a diagnosis?*
Has your child ever been hospitalised and/or had any serious illnesses?*
Do you have any concerns about your child’s hearing? Has your child had their hearing assessed? Please give date of last assessment and the result*
Do you have any concerns regarding your child’s vision?*
Other professionals
Has your child been referred or had any previous input from the NHS SLT service?*
Are there any other professionals involved in your child’s care?*
Signature of Parent*

Clear
Date*

DayMonthYear
Date
Parents may contact Sarah Dunne anytime to discuss their child’s speech and language development.

sarah.dunneslt1@gmail.com

Thank you for taking the time to complete this form.
Should be Empty:

Speech & Language Therapy Parental Consent and Home Information Form

Speech and language development:

Developmental History:

Home Information:

Background Information

Other professionals