Children S Speech and Language Therapy Service

Services for Children and Families

Children’s Speech and Language Therapy Service Pre School Referral Form for 0-5 Years

Send to: Speech and Language Therapy Admin Coral House 11 Longbow Close, Harlescott Lane, Shrewsbury SY1 3GZ Or Fax to: 01743 450801

Name of Child: ______Date of Birth: ______Age at Referral______

Address: ______

NHS Number (if known)______Sex M/F Ethnicity______

Parent/Carer Name(s):______

Parent/Carer Address (If Different)______

*Telephone Number______Preferred Contact Times______

* Telephone Contact Details – The first contact with the parent/carer(s) of may be by telephone. Please provide a current daytime telephone number

Home Language(s) ______Interpreter needed? Parent Yes  No□

Child Yes  No□ GP Address & Contact Name/Number______

Consultants Address & Contact Number______

Other Professionals Involved______CAF Yes  No□

Health Visitor______Early Years/ School______

Does the parent/carer consent to this referral and an initial assessment if required? No □ Yes □ Parent/Carer Signature………………………. Does your child have a Learning Disability? No □ Yes □ Don’t know □ Is this child known to Social Care? –Child in Care? Yes □ No □ Child Protection Plan? Yes □ No □ Child with Disabilities Plan? Yes □ No □ Referred By______Professional/ Relationship Child______

Contact Number/Address______

Date of Referral______Signature______For Service Use Only

Date Referral Received Caseload

Client Registration Number Added to Waiting List

“We welcome your Friends and Family feedback. You can do this by following the link http://www.shropscommunityhealth.nhs.uk/fft-survey or by filling in a feedback form available at Mike Ridley –Chairman clinics or from your health care professional.” Jan Ditheridge - Chief Shropshire Community Health NHS Trust Executive Services for Children and families SLT Pre-school referral Form/SLT/Masters/referral forms/Review May 2016 Early Speech and Language Development Chart Name Date of birth Stage and age Attention and listening Understanding of language Speech Sounds And Talk Social skills and use of language 0-11 months o Turns towards a familiar sound o Recognises parent’s voice o Communicates in a variety of ways - o Reaches out and points The Early o Startled by loud sounds o Understands frequently used words such as gurgling, crying, babbling o Makes vocal sounds to get attention Plays with speech sounds (bababa) > 10 Communicator o Watches face when someone talks “all gone”, “no”,” bye-bye” o o Tries to copy adult speech and lip movement o Stops and looks when hears own o Takes turns in conversations using babble name o Senses different emotions in carers voice and responds differently (quietening, laughing, smiling etc) > 12 8-20 months o Locates source of voice with accuracy o Gives named objects to adult o Babbling in strings of connected but o Uses gestures such as waving and pointing with First Word User o Pays attention to dominant stimulus (book,apple,car) different sounds ba-ba-no-no-go-go eye gaze to make requests and share interests o Enjoys music and singing o Understands simple instructions (“kiss o Reaches out or points to objects while o Plays alone but likes to be near familiar adult o Concentrates intently on an object or Mummy”, “where’s your nose”, “stop”) making speech sounds o Responds to words and interactive rhymes such activity of own choosing, for increasing o Recognises and points to objects, or pictures o Uses around 10 single words although as “clap hands” periods of time. > 20 in books if asked > 18 they may not be clear > 20 o Uses simple pretend play e.g. feeding teddy > 20 16-27 months o Responds to an adult talking and briefly o Understands 200-500 single words o Uses up to 50 words o Pretend play developing with toys (feeding a Combiner shifts attention from something they are o Understands simple instructions, containing o Begins to combine two or three simple doll or talking on telephone) doing to the speaker 2 key words without clues words > 36 o Follow adult body language including pointing, o Recognises and responds appropriately > 24 o Begins to ask simple questions (“where’s gesture and facial expression to many familiar sounds e.g. a knock on my drink?”) the door o Can be understood by familiar adult > 36

22-36 months o Listens with interest to the noises adults o Understands who, what, where questions o Uses a wide range of words including o Can take several turns in a conversation but Early sentence make when they read stories (but not why) descriptive language, time, space and jumps from topic to topic o Single channeled attention, can shift to o Identifies action words by pointing to the right function/action o Expresses emotion to adults and peers using user a different task if attention is first gained picture e.g. “who’s jumping” o Links 4-5 words together words not just actions by adult > 36 o Demonstrates understanding of the language o Able to use pronouns (me, him, she) o Has some favorite stories, songs and rhymes linked to early concepts including o Able to use prepositions (in on under) o Uses language to share ideas and experiences ‘in/on/under’, ‘big/little’ > 36 o Starting to use word endings (‘ing’, ‘s’) o Interested in others play and will join o Can be mostly understood by strangers in > 36 > 48 30-50 months o Enjoys listening to stories o Understands use of objects (“what do we use o Uses talk to connect ideas and explain o Understands turn-taking as well as sharing with Later sentence o Can shift attention between listening to to cut things?) what is happening adults and peers Shows understanding of prepositions Asks lots of why questions Initiates conversations user others and doing own activity without o o o adult prompt. Anticipates and joins in (behind, in front) o Can retell a simple past event in correct o Enjoys playing with peers with familiar actions and phrases in o Aware of time in terms of today, yesterday, order o Able to argue with adults or peers if they rhymes and stories tomorrow o Using more complex sentences > 48 disagree – uses words not just actions 40 -60 months o Sustains attentive listening, responding o Able to follow a simple story without pictures o Easily understood by adults and peers o Chooses own friends Skilled to what they have heard with comments, o Understands questions containing o Mostly uses well formed sentences o Generally co operative with playmates questions or actions Communicator sequencing words (what did you do after o Uses complex linking words appropriately, o Able to plan construction and make believe play o Maintains attention, concentrates and tea?) > 60 (‘and’, then’, because’ ) activities sits quietly when appropriate o Understands and enjoys rhyme o Takes longer turns in conversations o Two channeled attention- can listen and o Laughs at simple jokes o Maintains theme/topic of conversation do at the same time o Understands adjectives (soft, hard etc) o Uses language to organise sequence and o Demonstrates understanding of how and why clarify thinking questions by giving explanations o Introduces a storyline to their play > 72

Confidence: Whole group    Small group    Key person/familiar group    One to one    One to one (unfamiliar)    At home   “We welcome your Friends and Family feedback. You can do this by following the link Mike Ridley –Chairman http://www.shropscommunityhealth.nhs.uk/fft-survey or by filling in a feedback form available at Jan Ditheridge – Chief clinics or from your health care professional.” Executive Shropshire Community Health NHS Trust Services for Children and Families SLT Pre-school referral Form/SLT/Masters/referral forms/Review May 2016 60 12 6036 48 48 20 36 12 With thanks to Claire Vuckovic, Shropshire LA

“We welcome your Friends and Family feedback. You can do this by following the link Mike Ridley –Chairman http://www.shropscommunityhealth.nhs.uk/fft-survey or by filling in a feedback form available at Jan Ditheridge – Chief clinics or from your health care professional.” Executive Shropshire Community Health NHS Trust Services for Children and Families SLT Pre-school referral Form/SLT/Masters/referral forms/Review May 2016 Reasons for Referral to Speech and Language Therapy Service

Age of Child At Referral ______Yrs_____Mths (Please complete questions appropriate to child’s age)

NB If the child is stammering, please also complete the Stammering Checklist

REFER IF:

The Early Communicator Speech Sounds and Talk (0 – 11 months)  Not making or playing with speech sounds at 10 months

Social Skills and Use of Language

 Not sensing different emotions in carers voice and responding differently (questioning, laughing, smiling etc) by 12 months

First Word User Attention and Listening (8 – 20 Months)  Does not concentrate intently on an object or activity of own choosing for increasing periods of time by 20 months

Understanding of Language

 Does not recognise or point to objects or pictures in books if asked by 18 months

Speech Sounds and Talk

 Does not use 10 single words (may not be clear) at 20 months

 Does not use simple pretend play e.g. feeding teddy, by 20 months

Combiner Understanding of Language (16 – 27 Months)  Does not understand simple instructions containing 2 key words without clues by 24 months e.g. ‘Put teddy in bed’

 Does not begin to combine 2 to 3 simple words by 36 months e.g. “mummy go car”

 Cannot be understood by familiar adult by 36 months

“We welcome your Friends and Family feedback. You can do this by following the link Mike Ridley –Chairman http://www.shropscommunityhealth.nhs.uk/fft-survey or by filling in a feedback form available at Jan Ditheridge – Chief clinics or from your health care professional.” Executive Shropshire Community Health NHS Trust Services for Children and Families SLT Pre-school referral Form/SLT/Masters/referral forms/Review May 2016 NB Health Visitor Developmental Screen Occurs at This Point

Early Sentence User Attention and Listening (22 – 36 Months)  Cannot shift to a different task if attention is first gained by an adult at 36 months

Understanding of Language

 Cannot demonstrate understanding of language linked to early concepts by 36 months e.g. ‘show me the big cup’, ‘put teddy under the box’

 Cannot mostly be understood by strangers at 48 months

 Not interested in others play and does not join in at 36 months

Later Sentence Users Speech Sounds and Talk (30 – 50 Months)  Does not use complex sentences at 48 months. Not linking 2 ideas with ‘and’, ‘because’ e.g. “I go on bus and see Grandma”, “I like the park ‘cos I go on swings”

Skilled Communicator Understanding of Language (40 – 60 Months)  Doesn’t understand questions containing sequencing words by 60 months e.g. “what did you do after tea?”

 Doesn’t show understanding of ‘How?’ and ‘Why?’ questions by giving explanations by 72 months e.g. “why do you need wellies?”, “how do you get to school?”

Level of Parental Concern  Low  Medium  High

“We welcome your Friends and Family feedback. You can do this by following the link Mike Ridley –Chairman http://www.shropscommunityhealth.nhs.uk/fft-survey or by filling in a feedback form available at Jan Ditheridge – Chief clinics or from your health care professional.” Executive Shropshire Community Health NHS Trust Services for Children and Families SLT Pre-school referral Form/SLT/Masters/referral forms/Review May 2016 EVIDENCE IN SUPPORT OF REFERRAL

Observations / Responses in Play / Expressive Language Sample / Speech Sounds Sample

What kind of help are you providing already in your setting?

What advice have you given to the Parents / Carers?

“We welcome your Friends and Family feedback. You can do this by following the link Mike Ridley –Chairman http://www.shropscommunityhealth.nhs.uk/fft-survey or by filling in a feedback form available at Jan Ditheridge – Chief clinics or from your health care professional.” Executive Shropshire Community Health NHS Trust Services for Children and Families SLT Pre-school referral Form/SLT/Masters/referral forms/Review May 2016 Pre-Five Stammering Checklist

Please tick all that apply:-

 You or parent/s observe that the child shows signs of stammering

Please describe the stammer:

 There is a family history of stammering

 You or the parents think that the child is finding learning to talk difficult in any way

 The child is showing signs of being upset or frustrated about his speaking

 The child is struggling when talking

 The child is in a dual language situation and stammering in his first language

 There is parental concern or uneasiness

 The child’s general behaviour is causing concern

“We welcome your Friends and Family feedback. You can do this by following the link Mike Ridley –Chairman http://www.shropscommunityhealth.nhs.uk/fft-survey or by filling in a feedback form available at Jan Ditheridge – Chief clinics or from your health care professional.” Executive Shropshire Community Health NHS Trust Services for Children and Families SLT Pre-school referral Form/SLT/Masters/referral forms/Review May 2016