New referral form - CHILD

Childs Name:
Date of Birth:
Age:
Sex:
School / Preschool: 
Teachers name:
GP / Doctor:
NHI Number (if known):
Parents / Guardians:
Address:
Town / City:
Preferred appointment type:
Email:
Phone:
Communication concerns (please provide detail of difficulty/problem):
Is there any known family histry of speech and language difficulites? 
Previously seen by another SLT service? (please provide detail)

HEARING STATUS: Hearing is important to speech and language development and to learning. Hearing loss (for short periods of time or prolonged) can cause problems with speaking, using and understanding language, reading, school success, and social skills. 

Did your child pass their newborn hearing screen?
If your child is over 4 years old - Did your child pass their B4 school hearing and vision check?
Do you have any current concerns about hearing? 
How did you hear about GIANT LEAPS Speech Therapy?

PRIVACY STATEMENT: GIANT LEAPS Speech + Language Therapy collects personal information about their clients to support their assessment and therapy, and to ensure that effective services are provided. Information may be shared with other specialists and professional agencies necessary for the provision of our effective services. It is not compulsory for you to provide any personal information but we may not be able to provide the most effective services for you if you do not. You have the right to request access to, and correction of personal information held by GIANT LEAPS Speech + Language Therapy at any time.

Privacy Permission:

PLEASE READ OUR COMPREHENSIVE TERMS + CONDITIONS HERE

Agreement: