Self-referral form for LBU Speech and Language Therapy Clinic

Self-referral form for LBU Speech and Language Therapy Clinic

SLT clinic input will be carried out by speech and language therapy students at different levels of their course. Students are supervised by a qualified speech and language therapist.
Referral criteria

We will only accept your referral if you meet the following criteria:
- You are 18 years and over.
- Have a communication difficulty you acquired once you were aged 18 years or over.
- You have goals to work towards to support your communication, which can include understanding spoken language, reading, writing, and talking.
- You can give your consent to be referred to the clinic.
- You can travel to the clinic at Leeds Beckett University.
- You can take part in therapy sessions for a duration of 30-60 minutes.
- You have a stable medical condition.
- You are willing to work with speech and language therapy students.
I confirm that I am making the referral for myself

Confirm
My details
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of birth

DayMonthYear
Date
Phone number*
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Emergency contact
Name*

First NameLast Name
Type a question
Phone Number*
Please enter a valid phone number.Format: 00000 000 000.
Relationship*
Do you consent to this referral and for our service to contact you?

YesNo
How would you like us to contact you?

PhoneEmailPost
GP surgery:
Name of GP:
Telephone number:
What is your first language:
Do you need an interpreter?

YesNo
Do you give the clinic consent to contact your doctor (GP) if this is required

YesNo
Please tell us about your medical history:
Do you have any allergies?

YesNo
If yes, please give details:
Is your health or health condition stable?

YesNo
Do you have any difficulties with your eating and/or drinking?

YesNo
If yes, what food have you been recommended?

Level 7 regular foodLevel 7 easy-to-chew foodLevel 6 soft and bite-sized foodLevel 5 minced and moist foodLevel 4 pureed food
If yes, what drinks have you been recommended?

Level 0 thin fluidsLevel 1 slightly thick fluidsLevel 2 mildly thick fluidsLevel 3 moderately thick fluidsLevel 4 extremely thick fluids
How is your walking?

I can walk independentlyI use a walking stickI use an electric wheelchairI need help using my electric wheelchairI need to use a Wheelchair and need help
Do you need help going to the toilet?

YesNo
If yes, you will need to bring someone with you to help during your therapy sessions.
Vision and hearing
Do you wear glasses?

YesNo
Do you wear glasses for reading?

YesNo
Do you wear hearing aids?

YesNo
Speech and Language Therapy
Have you had therapy in the past for your communication?

YesNo
What did you work on in your sessions?
Describe what you find difficult about your communication.
Understanding people talking to you
Reading
Talking
Writing
Please tick the statements below that describe you best if you are finding it difficult to write in the boxes above:
Understanding conversation

I do not have any difficulties with my understandingI find it difficult to understand in conversations with more than 1 personI find it difficult to understand in conversations with 1 personI find it difficult to understand short instructions or sentencesI find it difficult to understand single words
Reading

I do not have any difficulties with my readingI can read paragraphs (3-4 lines of writing)I can read sentencesI can read some wordsI find it difficult to read
Talking

I do not have a difficulty with my speechI cannot find the words I want to say sometimesI cannot find the words I want to say most of the timeI find it hard to say words, and they can sound like a mixed-up wordI find it difficult to say any wordsMy speech sounds slurred, and people ask me to repeat myself
Writing

I do not have a difficulty with my writingI can write emails and lettersI can write words and sentencesI can write some simple wordsI can copy words when they are written for me
In the past I have been diagnosed with: (Tick all that apply)

Aphasia- A language disorder that may affect your ability to understand conversation, read, say the right words, or write words.Apraxia- A motor speech disorder that impacts your ability to plan and sequence the movements needed for clear speech.Dysarthria- A motor speech disorder that affects your ability to say words because your muscles may be weaker or less coordinated.
What would you like to work on? (Tick all that apply)

Understanding spoken words/sentences- Listening and understanding words, sentences and conversationReading-Single words, sentences, or longer pieces of writing.Talking- Finding the right words, talking in sentences, and having conversations.Writing- Writing words or sentences using handwriting or a computer/phone.Speech sounds- Working on improving the clarity of my speech.Confidence in my communication- Talking to family and friends, talking to others when out socialising, and practising my conversation skills.Using technology, such as apps, to support my communicationAttending group therapy- Meeting new people, having supported conversations and getting to know others.
I am aware that the therapy/interventions will be carried out by speech and language therapy students

YesNo
Signature*
Date:
Should be Empty:

Self-referral form for LBU Speech and Language Therapy Clinic

My details

Emergency contact

Please tell us about your medical history:

Vision and hearing

Speech and Language Therapy

Describe what you find difficult about your communication.

Please tick the statements below that describe you best if you are finding it difficult to write in the boxes above: