Adult Speech and Language Therapy (SALT)

Referral Form

Please note the following:

A referral to ENT is required prior to assessment for voice

A signature from a health professional is required for a swallowing assessment (e.g. AHP, GP, nurse)

GP should be within Herefordshire and/or Herefordshire address

Referrals for Head and Neck Cancer, Stroke, Head Injury and Learning Disability should be referred to the appropriate alternative teams

Please ensure all information is provided or the referral may not be accepted – see next page for referral form

Name	Date of birth
NHS No.
Address	Postcode
Postcode	Mobile number
Telephone Mobile Daytime contact number ☐ consent for initial contact by phone given.	GP Surgery
Is an interpreter needed?	Yes ☐ Language: __________________ No ☐
Reason for Referral: Communication ☐ Swallowing ☐ Details e.g. onset; relevant medical history; specifics regarding communication/swallow:

Prioritisation Communication Degree of impairment: mild ☐ moderate ☐ Severe ☐ Patient concern: mild ☐ moderate ☐ Severe ☐ Affecting ability to work: yes ☐ No ☐	Prioritisation Swallowing Recent/recurrent Chest infections: Yes ☐ No ☐ Frequent choking episodes: Yes ☐ No ☐ Significant weight loss in past 6 months: Yes ☐ No ☐ Rapidly progressing condition: Yes ☐ No ☐
Can this person attend as an outpatient? Yes ☐ No ☐ Can this person manage stairs Yes ☐ No ☐ If a home visit is necessary, do you have any concerns about lone workers?
Person completing this form: Name: Date of referral: Role: Telephone Number : Address: Email address: Signature:

Please email salt.hereford@nhs.net or post this referral to the address - Speech and Language Therapy Department, Wye Valley NHS Trust, Ruckhall Lane, Belmont, Hereford. HR2 9RP.

For further information regarding referral criteria search the Wye Valley NHS Trust Speech and Language Therapy website page – see below.

www.wyevalley.nhs.uk/visitors-and-patients/county-hospital-(acute)/a-z-departments/speech-and-language-therapy.aspx

For any further queries please call the SALT department on 01432 363975