Get referred to the MPC

REFERRAL TYPE (required)

—Please choose an option—Camden or Islington resident/ GPNewham 7+ resident or GPOther NHS referralPrivate pathway referral (Includes all non-UK referrals)

REASON FOR REFERRAL (required)

Advice and guidance to support local therapyIndividual therapy at the Michael Palin CentreGroup therapy at the Michael Palin Centre (ages 10 to 14 years)Group therapy at the Michael Palin Centre (ages 15 to 18;11 years)Parent only therapy group (under 7s)

CHILD OR YOUNG PERSON

First name (required)

Surname (required)

Date of birth (required)

Gender (required)
FemaleMaleOther

Gender (if you have selected "Other" from the above dropdown)

NHS no. (if known)

Home address (required)

Post code (required)

PARENT 1

First name (required)

Surname (required)

Home address (if different from above)

Post code

Email address (required)

Telephone number (required)

PARENT 2

First name

Surname

Home address (if different from above)

Post code

Email address

Telephone number

PARENTAL INVOLVEMENT

If you are a two parent family, both parents are required to attend the consultation until your child is 16 years old. If you are separated, we able to offer separate parent sessions.

Parents' status
TogetherSeparatedDivorced

Would you like to attend together or separately?
TogetherSeparately

If your child is over 16 please tell us if you would like to have a parent session.

I would like a parent session

Who has parental responsibility?

Please provide name(s) of other partners to be invited

SIBLINGS (names and ages). Siblings are not invited to the assessment.

SCHOOL/NURSERY

School name

School address

School post code

School headteacher

School telephone

School email

FAMILY DOCTOR

GP name

GP address

GP telephone number

GP email

EMERGENCY CONTACT

Name and number of the person we would contact if there were an emergency while you were at the Centre.

Name

Telephone number

NHS SPEECH AND LANGUAGE THERAPIST

Name

Address

Post code

Telephone number

Email address

When seen (currently or past)

INDEPENDENT SPEECH AND LANGUAGE THERAPIST

Name

Address

Post code

Telephone number

Email address

When seen (currently or past)

ETHNICITY

Child (required)
—Please choose an option—Any other white backgroundAsian or Asian British – BangladeshiAsian or Asian British – PakistaniAsian or Asian British - IndianAsian or Asian British – Any other Asian backgroundAny other mixed backgroundBlack or Black British - AfricanBlack or Black British – CaribbeanBlack or Black British – Any other black backgroundNot stated – Client refusedOther ethnic groups – ChineseOther ethnic groups – Any other ethnic groupWhite BritishWhite IrishWhite & Black CaribbeanWhite & Black AfricanWhite & Asian

Parent 1 (required)
—Please choose an option—Any other white backgroundAsian or Asian British – BangladeshiAsian or Asian British – PakistaniAsian or Asian British - IndianAsian or Asian British – Any other Asian backgroundAny other mixed backgroundBlack or Black British - AfricanBlack or Black British – CaribbeanBlack or Black British – Any other black backgroundNot stated – Client refusedOther ethnic groups – ChineseOther ethnic groups – Any other ethnic groupWhite BritishWhite IrishWhite & Black CaribbeanWhite & Black AfricanWhite & Asian

Parent 2
—Please choose an option—Any other white backgroundAsian or Asian British – BangladeshiAsian or Asian British – PakistaniAsian or Asian British - IndianAsian or Asian British – Any other Asian backgroundAny other mixed backgroundBlack or Black British - AfricanBlack or Black British – CaribbeanBlack or Black British – Any other black backgroundNot stated – Client refusedOther ethnic groups – ChineseOther ethnic groups – Any other ethnic groupWhite BritishWhite IrishWhite & Black CaribbeanWhite & Black AfricanWhite & Asian

RELIGION

Child (required)
—Please choose an option—Advaitin HinduAgnosticAhmadiAmishAnabaptistAncestor WorshipAnglicanAnimismAnthroposophistApostolic ChurchApostolic PentecostalistArmenian CatholicArmenian OrthodoxArya Samaj HinduAsatruarAshkenazi JewAtheistBaha'iBaptistBlack MagicBrahma KumariBrethrenBritish IsraeliteBuddhistBulgarian Orthodox ChurchCalvinistCatholic: Not Roman CatholicCeltic ChristianCeltic Orthodox ChurchCeltic PaganChinese Evangelical ChristianChondogyoChristadelphianChristianChristian ExistentialistChristian HumanistChristian ScientistChristian ScientistsChristian Spiritualist ChurchChurch in WalesChurch of EnglandChurch of God of ProphecyChurch of IrelandChurch of ScotlandConfucianistCongregational ChurchCongregationalistCoptic Orthodox ChurchDeistDruzeEastern CatholicEastern Orthodox ChurchElim PentecostalistEthiopian OrthodoxEvangelical ChristianExclusive BrethrenFour Square GospelFree ChurchFree Church of ScotlandFree Evangelical PresbyterianFree MethodistFree PresbyterianFrench ProtestantGoddessGreek CatholicGreek OrthodoxHaredi JewHasidic JewHeathenHinduHumanistIndependent MethodistIndian OrthodoxInfinite WayIsmaili MuslimJainJehovah's WitnessJewishJudaic ChristianKabbalistLiberal JewLightworkerLutheranMahayana BuddhistMasorti JewMennoniteMessianic JewMethodistMoravianMormonMuslimNative American ReligionNew Age PractitionerNew Kadampa Tradition BuddhistNew Testament PentacostalistNichiren BuddhistNonconformistNot ReligiousOccultOccultistOld CatholicOpen BrethrenOrthodox ChristianOrthodox JewPaganPantheismPantheistPatient Religion UnknownPentecostalPentecostalistPeyotistPlymouth BrethrenPresbyterianProtestantPure Land BuddhistQuakerRadha SoamiRastafariReform JewReformed ChristianReformed PresbyterianReformed ProtestantRoman CatholicRomanian OrthodoxRussian Orthodox ChurchSalvation ArmySanteriSatanismScientologistScottish EpiscopalianScottish PresbyterianSecularistSerbian Orthodox ChurchSeventh Day AdventistShakti HinduShamanShi'ite MuslimShintoShiva HinduShumeiSikhSpiritualistSunni MuslimSwedenborgianSyrian OrthodoxTaoistTheravada BuddhistTibetan BuddhistUkrainian CatholicUkrainian Orthodox ChurchUniate CatholicUnitarianUnitarian-UniversalistUnited Reformed ChurchUniversalistVaishnava HinduVodunWiccanYorubaZen BuddhistZwinglian

Parent 1 (required)
—Please choose an option—Advaitin HinduAgnosticAhmadiAmishAnabaptistAncestor WorshipAnglicanAnimismAnthroposophistApostolic ChurchApostolic PentecostalistArmenian CatholicArmenian OrthodoxArya Samaj HinduAsatruarAshkenazi JewAtheistBaha'iBaptistBlack MagicBrahma KumariBrethrenBritish IsraeliteBuddhistBulgarian Orthodox ChurchCalvinistCatholic: Not Roman CatholicCeltic ChristianCeltic Orthodox ChurchCeltic PaganChinese Evangelical ChristianChondogyoChristadelphianChristianChristian ExistentialistChristian HumanistChristian ScientistChristian ScientistsChristian Spiritualist ChurchChurch in WalesChurch of EnglandChurch of God of ProphecyChurch of IrelandChurch of ScotlandConfucianistCongregational ChurchCongregationalistCoptic Orthodox ChurchDeistDruzeEastern CatholicEastern Orthodox ChurchElim PentecostalistEthiopian OrthodoxEvangelical ChristianExclusive BrethrenFour Square GospelFree ChurchFree Church of ScotlandFree Evangelical PresbyterianFree MethodistFree PresbyterianFrench ProtestantGoddessGreek CatholicGreek OrthodoxHaredi JewHasidic JewHeathenHinduHumanistIndependent MethodistIndian OrthodoxInfinite WayIsmaili MuslimJainJehovah's WitnessJewishJudaic ChristianKabbalistLiberal JewLightworkerLutheranMahayana BuddhistMasorti JewMennoniteMessianic JewMethodistMoravianMormonMuslimNative American ReligionNew Age PractitionerNew Kadampa Tradition BuddhistNew Testament PentacostalistNichiren BuddhistNonconformistNot ReligiousOccultOccultistOld CatholicOpen BrethrenOrthodox ChristianOrthodox JewPaganPantheismPantheistPatient Religion UnknownPentecostalPentecostalistPeyotistPlymouth BrethrenPresbyterianProtestantPure Land BuddhistQuakerRadha SoamiRastafariReform JewReformed ChristianReformed PresbyterianReformed ProtestantRoman CatholicRomanian OrthodoxRussian Orthodox ChurchSalvation ArmySanteriSatanismScientologistScottish EpiscopalianScottish PresbyterianSecularistSerbian Orthodox ChurchSeventh Day AdventistShakti HinduShamanShi'ite MuslimShintoShiva HinduShumeiSikhSpiritualistSunni MuslimSwedenborgianSyrian OrthodoxTaoistTheravada BuddhistTibetan BuddhistUkrainian CatholicUkrainian Orthodox ChurchUniate CatholicUnitarianUnitarian-UniversalistUnited Reformed ChurchUniversalistVaishnava HinduVodunWiccanYorubaZen BuddhistZwinglian

Parent 2
—Please choose an option—Advaitin HinduAgnosticAhmadiAmishAnabaptistAncestor WorshipAnglicanAnimismAnthroposophistApostolic ChurchApostolic PentecostalistArmenian CatholicArmenian OrthodoxArya Samaj HinduAsatruarAshkenazi JewAtheistBaha'iBaptistBlack MagicBrahma KumariBrethrenBritish IsraeliteBuddhistBulgarian Orthodox ChurchCalvinistCatholic: Not Roman CatholicCeltic ChristianCeltic Orthodox ChurchCeltic PaganChinese Evangelical ChristianChondogyoChristadelphianChristianChristian ExistentialistChristian HumanistChristian ScientistChristian ScientistsChristian Spiritualist ChurchChurch in WalesChurch of EnglandChurch of God of ProphecyChurch of IrelandChurch of ScotlandConfucianistCongregational ChurchCongregationalistCoptic Orthodox ChurchDeistDruzeEastern CatholicEastern Orthodox ChurchElim PentecostalistEthiopian OrthodoxEvangelical ChristianExclusive BrethrenFour Square GospelFree ChurchFree Church of ScotlandFree Evangelical PresbyterianFree MethodistFree PresbyterianFrench ProtestantGoddessGreek CatholicGreek OrthodoxHaredi JewHasidic JewHeathenHinduHumanistIndependent MethodistIndian OrthodoxInfinite WayIsmaili MuslimJainJehovah's WitnessJewishJudaic ChristianKabbalistLiberal JewLightworkerLutheranMahayana BuddhistMasorti JewMennoniteMessianic JewMethodistMoravianMormonMuslimNative American ReligionNew Age PractitionerNew Kadampa Tradition BuddhistNew Testament PentacostalistNichiren BuddhistNonconformistNot ReligiousOccultOccultistOld CatholicOpen BrethrenOrthodox ChristianOrthodox JewPaganPantheismPantheistPatient Religion UnknownPentecostalPentecostalistPeyotistPlymouth BrethrenPresbyterianProtestantPure Land BuddhistQuakerRadha SoamiRastafariReform JewReformed ChristianReformed PresbyterianReformed ProtestantRoman CatholicRomanian OrthodoxRussian Orthodox ChurchSalvation ArmySanteriSatanismScientologistScottish EpiscopalianScottish PresbyterianSecularistSerbian Orthodox ChurchSeventh Day AdventistShakti HinduShamanShi'ite MuslimShintoShiva HinduShumeiSikhSpiritualistSunni MuslimSwedenborgianSyrian OrthodoxTaoistTheravada BuddhistTibetan BuddhistUkrainian CatholicUkrainian Orthodox ChurchUniate CatholicUnitarianUnitarian-UniversalistUnited Reformed ChurchUniversalistVaishnava HinduVodunWiccanYorubaZen BuddhistZwinglian

LANGUAGES SPOKEN

Child

Parent(s)

Does your child need an interpreter? (required)
YesNo

Does the parent / do the parents need an interpreter? (required)
YesNo

STAMMERING

When did your child begin to stammer?
When did your child begin to stammer

Has it changed since then?
Has it changed since then?

When do they stammer more?
When do they stammer more?

When does it happen less?
When does it happen less?

Do you have any idea(s) about why your child started to stammer?
Do you have any idea(s) about why your child started to stammer?

Any other members of the extended family who stammer now or used to stammer?
Any other members of the extended family who stammer now or used to stammer?

What does your child do when they stammer?
What does your child do when they stammer?

How do you refer to stammering when talking to your child?
How do you refer to stammering when talking to your child

ADDITIONAL INFORMATION

SPEECH AND LANGUAGE ASSESSMENTS

Please email copies of reports to: [email protected]

Previous therapy and progress
Previous therapy

Up-to-date language assessment (for SLT referrals)
Up-to-date assessment

Additional needs (e.g. medical, social, educational, emotional)
Additional needs

Other professionals involved (e.g. CAMHS, Occupational Therapy, Social Services)
Other professionals

Any other information
Other information

RESEARCH (for parents)

Occasionally at the Michael Palin Centre we conduct research studies to investigate stammering. If you would like to receive information about research studies in which you and/or your child can participate then please indicate below. You do not have to commit or participate in any of the studies. You can withdraw from receiving this information at any time without giving any reason.

Would you like to receive information?

YesNoDon't Know

NAME OF REFERRER (the person who fills in this form / who initiates this referral)

Contact details if different from above (name is required)

If you would like a printed copy of your completed referral form, please hit ctrl + ‘p’ (on a PC) or cmd + ‘p’ (on a Mac) before you click submit/send.

You will receive an automated email to confirm that your referral has been received.

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