Referral to the community Speech and Language Therapy service

Please select your area (Required)

Bexhill

Eastbourne

Hailsham

Hastings and St Leonards

Rural Rother

Seaford

Wealden

I have read the information at the top of this page and confirm that I consent/have received consent from the person named on the referral form. Patients can also be referred in their best interests if indicated. Please complete all the following questions so that we can prioritise the referral correctly. It is important to be accurate with your answers so that we have all the necessary information. Referrals will only be received from people with a medical background or people who have completed the ESHT SLT Level 1 and Level 2 Dysphagia Training. Referrals will be returned if this training hasn’t been completed. (Required)

Yes - I confirm

Referrer's details

Name of referrer (Required)

First

Last

Job title (Required)

Contact phone number (Required)

Email of referrer (Required)

Details of person who requires assessment

Name (Required)

First

Last

Gender (Required)

Date of birth (Required)

Address (Required)

Email (Required)

Preferred contact Number (Required)

NHS number (if known)

If you don't know your NHS Number, you can find it at: Find your NHS number

Do you require an Interpreter (Required)

Yes
No

If Yes, what language (Required)

Medical history

Enter details or upload document below.

Medical history/patient letter file upload

Accepted file types: pdf, doc, png, jpg, Max. file size: 3 MB.

Is the referral for

Swallowing problems
Communication problems
Both

Current food and drink/SLT recommendations

Chest infection

Yes
No

Weight loss

Yes
No

Please describe your concerns

Assessment type

Please select all that are possible

Clinic
Home visit
Virtual consultation (video/telephone)

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Referral to the community Speech and Language Therapy service

Community Speech and Language Therapy Referral

Referrer's details

Details of person who requires assessment

Referral information for healthcare professionals