SLT REFERRAL PROCESS If you have any concerns about a client’s eating and drinking, complete the following 2 forms: a) General details b) Triage forms.

SLT REFERRAL PROCESS

If you have any concerns about a client’s eating and drinking, complete the following 2 forms:

a)General detailsb) Triage forms

Fax or send these referrals through the postIncomplete forms will be returned.

SLT Referral Form: general details

THIS REFERRAL WILL NOT BE ACCEPTED UNLESS THE FORM IS FULLY COMPLETED

NHS Number

Date of Birth

First name

Surname

Address Ward Name

Post Code

Tel No.

GP Name

Address:

Post Code Tel No. Consultant

Reasons for referral / current difficulties

Consent obtained □ (please tick)

Swallowing (please fully complete the additional information overleaf) Communication Relevant Medical History including any confirmed diagnosis

Further Information:- HOME VISITS WILL ONLY BE OFFERED IF THE PATIENT IS HOUSEBOUND

Lives Alone? Key safe number:

Lives with carer?

Carers – state number and timings of visits if known

Is the client housebound? Please state other professionals involved with this patient

Are there any risks associated with home visiting?

Has there been any previous SLT involvement?

Referred by Print Name Signature Designation Phone No Pager Date

Please return completed forms to: Speech and Language Therapy Dept, Stafford Hospital, Weston Road, Stafford, ST16 3SA, Telephone: 01785 257731 ext 4207 / FAX: 01785 230931

Community Speech and Language Therapy Services Referral Form for Adult Services

Referral Form: Triage Form

*First name *Surname

*NHS No *DOB D D M M M Y Y Y Y

Community Speech and Language Therapy Services Additional information for people with swallowing difficulties

NHS Number

Date of Birth D D M M M Y Y Y Y

First name

Surname

To be fully completed in addition to the referral form Name of person answering questions Role of person answering questions: e.g. service user, spouse, partner, carer, nurse, doctor

Date when this form was completed

Questions – to assist with prioritisation Yes/No Comments

Does he/she have difficulty staying awake for more than 10 minutes?

Is he/she coughing/choking on food? If yes, how frequently?

Is he/she coughing/choking on fluids? If yes, how frequently?

Is this a recent difficulty?

Has he/she had recurring chest infections over the last 6 months?

Has he/she currently got a chest infection?

Does he/she get short of breath when eating and drinking?

Has he/she lost weight over the last 3 months?

Does he/she have a reduced appetite?

Does he/she demonstrate any unusual behaviours at mealtimes (please circle)? storing food spitting food out fast eating

slow eating other:

Does he/she have a PEG (feeding tube)?

What food is he/she currently eating? - Eg normal diet, pureed diet

What fluid is he/she currently drinking? - Eg normal fluids, syrup thick fluids

Is he/she able to feed themsleves?

For SLT office use Date received: Is the form complete? Yes No

If no, date of return to the referrer:

For SLT Clinician use Designation

Reviewed by (Print name) Signature

Date Time

Speech & Language Therapy Contact Details

• Lichfield: Samuel Johnson Hospital: 01543 412900 ext 3001

• Tamworth: Sir Robert Peel Hospital: 01827 263800 ext 8227

• North Staffs and Stoke-on-Trent:Bentilee Neighbourhood Centre: 01782 234481/2/3

• Cannock: Cannock Chase Hospital: 01543 576414• Stafford: County Hospital: 01785 230207• Stone & Eccleshall: Stone Rehabilitation Service

01785 816917