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Speech & Language Therapy Department
Patient Services
3rd Floor
Regent Point
Regent Farm Road
APP upon Tyne
NE3 3HD
Tel: 0191 233 6161
www.newcastle-hospitals.nhs.ukTel:
Email:0191 282 3085
0191 282 3428
HYPERLINK "mailto:nuth.PaediatricSpeechandLanguageTherapy@nhs.net" nuth.PaediatricSpeechandLanguageTherapy@nhs.net
Speech and Language Therapy
Referral form 16 25 Service
Please complete all boxes and return to the address on the final page for the referral to be processed. We may return referrals if key information has not been included.
Please note:
Students must have and Education Health And Care Plan (EHCP) and SALT must be listed as a need in Section G of their EHCP.
Consent must be obtained from young person or parent/carer (if the young person does not have capacity to consent)
Please check to see if the student is already known (currently or previously) to CTLD (Community Team for Learning Disabilities) in which case, they should be referred to CTLD.
Referrals for young people who stammer should be sent to speech and language therapy (SALT) departments for children and young people or adults.
Name of student:
Date of birth:
TO BE COMPLETED BY THE STUDENT (with support as required)
Do you feel you may benefit from Speech and Language Therapy (SALT) input in any of the following areas: (Please tick any that apply):
Pronouncing words
Understanding what people say to you
Social communication skills
Speaking in longer sentences
Self esteem/confidence
Problem solving
Presentation skills/interview skills
If you have had previous SALT input , what did you focus on?
If available, how would you like to be seen?
At home
Individually in 6th form/college
Small groups (if possible) in 6th form/college
Other/informal setting (please state) -
Anything else you would like us to know:
Are there any specific tasks/activities you would like SALT to support?
Signature: ate:
TO BE COMPLETED BY THE REFERRER
There are 2 sections in this referral, both must be completed
What best describes the students gender, e.g. male, female, prefer to describe differently, prefer not to say?
NHS number (if known):
Address:
Postcode: Telephone number:
Email address (so we can send links to helpful resources):
Name of 6th form/college
Is the student a Child in Care (CIC) if under 18 years? Y e s / N o
I f a C I C , p l e a s e p r o v i d e t h e n a m e a n d a d d r e s s o f t h e p e r s o n w h o h a s p a r e n t a l r e s p o n s i b i l i t y :
H o m e l a n g u a g e s :
E t h n i c i t y :
& B a n g l a d e s h i o r B r i t i s h B a n g l a d e s h i & B l a c k A f r i c a n & C a r i b b e a n & C h i n e s e
& E t h n i c C a t e g o r y n o t s t a t e d & E t h n i c G r o u p n o t g i v e n ( r e f u s e d ) & I n d i a n o r B r i t i s h I n d i a n & O t h e r
& O t h e r A s i a n B a c k g r o u n d &O t h e r B l a c k B a c k g r o u n d & O t h e r M i x e d B a c k g r o u n d &O t h e r w h i t e b a c k g r o u n d
& P a k i s t a n i o r B r i t i s h P a k i s t a n i & W h i t e a n d A s i a n & W h i t e a n d B l a c k A f r i c a n & W h i t e a n d B l a c k C a r i b b e a n & W h i t e B r i t i s h & W h i t e I r i s h
I s a n i n t e r p r e t e r r e q u i r e d ? Y e s / N o
G P n a m e a n d p r a c t i c e :
What are you hoping for from this referral?
Does the individual share the same concerns as professionals? What are their views of their communication skills?
Primary areas of concern ( please tick)
Students ability to understand what is said to them
Use of spoken language
Pronunciation of words (use of speech sounds)
Social skills and appropriate interaction
Other (please specify)
Please give as much information as possible about your concerns.
Please tick any statements that describe this young person
Has unclear speech
Uses mostly short phrases of two to four words
Uses longer sentences which are sometimes jumbled
Uses good grammatical sentences but content is inappropriate to the situation
Has difficulty understanding what is said to them
Has difficulty in initiating and maintaining friendships
Has difficulty in recognizing and/re describing emotions?
Does the student have any other physical / medical / developmental additional needs? Please specify and provide details below
Hearing:
Vision:
Hospital involvement:
Learning
Physical
Other:
Are any other professionals involved? Please detail below.
Please attach any relevant reports and letters (including those from professionals).
What additional support does the student currently receive in 6th form/college? Please comment on type, aims and amount.
Please comment on the students behaviour and 6th form/college attendance
Page PAGE 3 of NUMPAGES 7
This form is current from May 2026 to May 2027: a weblink to the current form is provided on the last page. Please use the correct form.
Name and address of referrer:
Contact number of referrer:
Email address of referrer:
Profession of referrer:
The young persons consent must be obtained for this referral, and the content of the referral form agreed with them.
By signing this referral, I confirm that I have:
Discussed all the information on this form with the young person
Obtained young persons consent for speech and language assessment/input
OR
Discussed referral and obtained parent/carer consent if young person lacks the capacity to consent to own treatment.
Obtained consent for speech and language therapy information about the young person to be added to secure electronic NHS systems
Young persons consent given: YES / NO (please circle)
Referrers name:
Referrers Signature:
Date:
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Referrer signature:
Date:
Please return the completed form to
Paediatric Speech and Language Therapy
3rd Floor, Regent Point
Regent Farm Road
APP upon Tyne
NE3 3HD
Or email to:HYPERLINK "mailto:nuth.PaediatricSpeechandLanguageTherapy@nhs.net"nuth.PaediatricSpeechandLanguageTherapy@nhs.net
Tel: 0191 282 3085/3428
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