Referral

REFERRAL TYPE(Required)

CHILD OR YOUNG PERSON

DD slash MM slash YYYY

PARENT 1

Title
DD slash MM slash YYYY

PARENT 2

Title
DD slash MM slash YYYY

PARENT 3

Title
DD slash MM slash YYYY

PARENT 4

Title
DD slash MM slash YYYY

PARENTAL INVOLVEMENT

Both parents are required to attend the consultation for children up to 16 years old.

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

I would like a parent session
Parents' status
Would you like to attend together or separately?

SCHOOL/NURSERY

FAMILY DOCTOR

YOUR LOCAL NHS TRUST

EMERGENCY CONTACT

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

NHS SPEECH AND LANGUAGE THERAPIST

Name, address, telephone and email

INDEPENDENT SPEECH AND LANGUAGE THERAPIST

Ethnicity

LANGUAGES SPOKEN

Does your child need an interpreter?(Required)
Does the parent / do the parents need an interpreter?(Required)

STAMMERING

REASON FOR REFERRAL

Please hold down 'ctrl' (PC) or 'cmd' (Mac) buttons in order to select more than one option.

ADDITIONAL INFORMATION

SPEECH AND LANGUAGE ASSESSMENTS

Please send copies of reports to:

Administrator
The Michael Palin Centre
13-15 Pine Street
London EC1R 0JG

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 don hot 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?

NAME OF REFERRER

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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I would like to become a friend of the Michael Palin Centre for Stammering and receive emails with news and information about the Centre and fundraising events.

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I’m also happy for the Michael Palin Centre to call me occasionally about supporting the Centre’s work.
Charitable donations to the Michael Palin Centre are administered by The Whittington Health Charity, Registered Charity Number 1056452 www.whittingtonhealthcharity.org. For this purpose alone, The Whittington Health Charity will also hold your details. We take your privacy seriously and will never sell or swap your details with other third parties. You can withdraw your consent to be contacted at any time by calling 020 3316 8100 or by emailing [email protected] Information about how the Trust protects personal data is set out in our privacy policy.
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