Adult speech and language referral form :: Medway Community Healthcare

Speech and language therapy - Adult

To find out how we use this information, our security and your rights visit our privacy page.

You will see a thank you page once the form has been submitted. If you do not see this page then you have overlooked to complete some of the required fields. Please check the form, complete the missing details and resubmit. Thank you.

Patient details

First Name: *Required

Surname *Required

Date of birth: *Required

NHS number: *Required

Telephone number:

Mobile number:

GP (name and address): *Required

Are you requesting assessment of: *Required

Swallowing

Communication (voice, speech, language and/or stammering)

Swallowing and communication

Medical history including medication *Required

Does the patient have any of the following (tick all that apply)

Recurrent chest infection

Unexplained weight loss

Voice changes

Difficulty controlling their saliva

Description of difficulty: Symptoms causing concern; observations (nature of onset, progression of symptoms, current management, investigations pending). Providing these details allows us to triage your referral more efficiently. *Required

Referrer details

Name of referrer: *Required

Role of referrer: *Required

Address for correspondence: *Required

Telephone number: *Required

Date *Required

I agree to the privacy policy.

Service Users, Families, Friends and Carers

Health, Care and Education Professionals

Work for us

Adult speech and language referral form

Speech and language therapy - Adult

How to find us

Facilities and other info

Opening Times

Get in touch

Service Users, Families, Friends and Carers

Health, Care and Education Professionals

Work for us

Adult speech and language referral form

Speech and language therapy - Adult

How to find us

Facilities and other info

Opening Times

Accessibility tools