Family or carer completing referral form for LBU Speech and Language Therapy Clinic

Family or carer completing 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 a family member or carer making the referral.

Confirm
Your details
Name

First NameLast Name
Client relationship
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone number*
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Client's 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.
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Emergency contact
Name*

First NameLast Name
Relationship*
Phone number*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Has the person agreed for you to refer them to LBU speech and language therapy clinic?

YesNo
If no, why?
Has the client consented to you sharing confidential information on this form?

YesNo
Has the client consented to our service contacting them?

YesNo
What's the best method of contacting the client?

PhoneEmailPost
Client's GP surgery:
Name of GP:
Telephone number:
Client's first language:
Does the client require an interpreter?

YesNo
Does the client give the clinic consent to contact their doctor (GP) if this is required?

YesNo
Medical diagnosis and relevant medical history:
Does the client have any allergies?

YesNo
If yes, please give details:
Is the client's health or medical condition stable?

YesNo
Does the client have any difficulties with eating and/or drinking?

YesNo
If yes, what food have they 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 they been recommended?

Level 0 thin fluidsLevel 1 slightly thick fluidsLevel 2 mildly thick fluidsLevel 3 moderately thick fluidsLevel 4 extremely thick fluids
How does the client mobilise?

Can walk independentlyUses a walking stickCan use an electric wheelchair independentlyNeeds help using their electric wheelchairUses a wheelchair and needs help
Does the client need help to go to the toilet?

YesNo
If yes, the client will need to be accompanied during therapy sessions.
Vision and hearing
Does the client wear glasses?

YesNo
Does thew client wear glasses for reading?

YesNo
Does the client wear hearing aids?

YesNo
Speech and Language Therapy
Has the client had therapy in the past?

YesNo
Please describe the client’s communication abilities below:
Understanding people talking to you
Understanding people talking to them instead of you
Reading
Talking
Writing
Please tick the statements that best fit the client's presentation if you are unable to complete the information 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, has the client been diagnosed with any of the following conditions: (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 the client like to work on during the therapy sessions? (Tick all that apply)

Understanding spoken words/sentences- Listening and understanding conversation, television programmes, etcReading-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.
The client and I are aware that the therapy/interventions will be carried out by speech and language therapy students (Tick box to indicate read and agreed)

YesNo
Signature*
Date:
Should be Empty:

Family or carer completing referral form for LBU Speech and Language Therapy Clinic

Your details

Client's details

Emergency contact

Medical diagnosis and relevant medical history:

Vision and hearing

Speech and Language Therapy

Please describe the client’s communication abilities below:

Please tick the statements that best fit the client's presentation if you are unable to complete the information above.