Referral Form

FILL OUT THIS FORM IF YOU WISH TO REFER A CHILD OR YOUNG PERSON TO THE MICHAEL PALIN CENTRE FOR AN ASSESSMENT.

ALL fields marked * need to be completed for your referral to be accepted

REFERRAL TYPE* Private
NHS

CHILD OR YOUNG PERSON

First name*

Surname*

Date of Birth*(dd/mm/yyyy)

Gender*

NHS No.(if known)

Home Address*

PARENT 1

First name*

Surname*

Title (e.g. Mr,Ms, Mrs, Dr)*

Date of Birth*(dd/mm/yyyy)

NHS No.(if known)

Address(if different from above)

Email*

Telephone number*

PARENT 2

First name

Surname

Title (e.g. Mr, Dr, Mrs, Ms)

Date of Birth(dd/mm/yyyy)

NHS No.(if known)

Address(if different from above)

Telephone number

PARENTAL INVOLVEMENT

Both parents are required to attend the consultation for children up to 16 years old.

If your child is over 16 please tell us if you would like to have a parent session

Who has parental responsibility

Parents’ status* together
separated
divorced

Would you like to attend together or separately

Please give name(s) of other partners to be invited

SIBLINGS (names and ages)Siblings are not invited to the assessment

SCHOOL/NURSERY

Name and Address of School*

School Head Teacher

School Telephone

School Email

FAMILY DOCTOR

GP Name

GP Address*

GP Telephone number

GP Email

YOUR LOCAL NHS TRUST

Name

EMERGENCY CONTACT

name and number of the person we would contact if there were an emergency while you were at the Centre.

Name*

Telephone Number*

NHS SPEECH AND LANGUAGE THERAPIST

Name

Address

Telephone number

NHS Trust

Email address

When seen (currently or past)

NHS SLT Manager (to be completed by SLT)

INDEPENDENT SPEECH AND LANGUAGE THERAPIST

Name

Address

Telephone number

Email address

When seen (currently or past)

LANGUAGES SPOKEN

Child

Parent(s)

Does your child need an interpreter* Yes
No

Do parents need an interpreter* Yes
No

STAMMERING

Onset of stammer

Has it changed since then

When do they stammer more

When does it happen less

Do you have any idea(s) about why your child started to stammer

Any other members of the extended family who stammer now or used to stammer

What does your child do when he/she stammersr

How do you refer to the problem when talking to your child

REASON FOR REFERRAL

Advice and guidance to support local therapy

Individual therapy at the Michael Palin Centre

Group therapy at the Michael Palin Centre (ages 10 to 18 years)

Additional Information

SPEECH AND LANGUAGE ASSESSMENTS

Please send copies of reports to Administrator The Michael Palin Centre 13-15 Pine Street London EC1R 0JG’

PREVIOUS THERAPY AND PROGRESS

UP TO DATE LANGUAGE ASSESSMENT (for SLT referrals)

ADDITIONAL NEEDS (e.g. medical, social, educational, emotional)

OTHER PROFESSIONALS INVOLVED (e.g. CAMHS, Occupational Therapy, Social Services)

ANY OTHER INFORMATION

RESEARCH (for parents)

Occasionally at the Michael Palin Centre we conduct research studies to investigate stammering. If you would like to receive information about research studies in which you and/or your child can participate then please indicate below. You do not have to commit or participate in any of the studies. You can withdraw from receiving this information at any time without giving any reason.

Would you like to receive information

Name of referrer