Refer to the MPC

REFERRAL TYPE

PrivateNHS

CHILD OR YOUNG PERSON

First name (required)

Surname (required)

Date of birth (required)

Gender (required)
FemaleMaleOtherPrefer not to say

NHS no. (if known)

Home address (required)

Post code (required)

PARENT 1

First name (required)

Surname (required)

Title [e.g. Mr., Ms., Mrs., Dr., etc.]:

Date of birth (required)

NHS no. (if known)

Home address (if different from above)

Post code

Email address (required)

Telephone number (required)

PARENT 2

First name

Surname

Title [e.g. Mr., Ms., Mrs., Dr., etc.]:

Date of birth

NHS no. (if known)

Home address (if different from above)

Post code

Email address

Telephone number

PARENT 3

First name

Surname

Title [e.g. Mr., Ms., Mrs., Dr., etc.]:

Date of birth

NHS no. (if known)

Home address (if different from above)

Post code

Email address

Telephone number

PARENT 4

First name

Surname

Title [e.g. Mr., Ms., Mrs., Dr., etc.]:

Date of birth

NHS no. (if known)

Home address (if different from above)

Post code

Email address

Telephone number

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

Who has parental responsibility?

Parents' status
TogetherSeparatedDivorced

Would you like to attend together or separately?
TogetherSeparately

Please provide name(s) of other partners to be invited and enter their details in PARENT 2, 3 and/or 4 section

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

YOUR LOCAL NHS TRUST

Name

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

NHS Trust

Email address

When seen (currently or past)

NHS SLT Manager (to be completed by SLT)
Name, address, telephone and email

INDEPENDENT SPEECH AND LANGUAGE THERAPIST

Name

Address

Post code

Telephone number

Email address

When seen (currently or past)

ETHNICITY

Child (required)
White BritishWhite IrishAny other white backgroundWhite & black CaribbeanWhite & black AfricanWhite & AsianAny other mixed backgroundAsian or Asian British - IndianAsian or Asian British - PakistaniAsian or Asian British - BangladeshiAsian or Asian British - any other Asian backgroundBlack or black British – CaribbeanBlack or black British – AfricanBlack or black British – any other backgroundOther Ethnic Groups - ChineseOther Ethnic Groups - any other ethnic groupI would prefer not to say

Parent 1 (required)
White BritishWhite IrishAny other white backgroundWhite & black CaribbeanWhite & black AfricanWhite & AsianAny other mixed backgroundAsian or Asian British - IndianAsian or Asian British - PakistaniAsian or Asian British - BangladeshiAsian or Asian British - any other Asian backgroundBlack or black British – CaribbeanBlack or black British – AfricanBlack or black British – any other backgroundOther Ethnic Groups - ChineseOther Ethnic Groups - any other ethnic groupI would prefer not to say

Parent 2
White BritishWhite IrishAny other white backgroundWhite & black CaribbeanWhite & black AfricanWhite & AsianAny other mixed backgroundAsian or Asian British - IndianAsian or Asian British - PakistaniAsian or Asian British - BangladeshiAsian or Asian British - any other Asian backgroundBlack or black British – CaribbeanBlack or black British – AfricanBlack or black British – any other backgroundOther Ethnic Groups - ChineseOther Ethnic Groups - any other ethnic groupI would prefer not to say

Parent 3
White BritishWhite IrishAny other white backgroundWhite & black CaribbeanWhite & black AfricanWhite & AsianAny other mixed backgroundAsian or Asian British - IndianAsian or Asian British - PakistaniAsian or Asian British - BangladeshiAsian or Asian British - any other Asian backgroundBlack or black British – CaribbeanBlack or black British – AfricanBlack or black British – any other backgroundOther Ethnic Groups - ChineseOther Ethnic Groups - any other ethnic groupI would prefer not to say

Parent 4
White BritishWhite IrishAny other white backgroundWhite & black CaribbeanWhite & black AfricanWhite & AsianAny other mixed backgroundAsian or Asian British - IndianAsian or Asian British - PakistaniAsian or Asian British - BangladeshiAsian or Asian British - any other Asian backgroundBlack or black British – CaribbeanBlack or black British – AfricanBlack or black British – any other backgroundOther Ethnic Groups - ChineseOther Ethnic Groups - any other ethnic groupI would prefer not to say

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

Onset of stammer
Onset of stammer

Has it changed since then?
Has it changed?

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 ideas about why your child started to stammer?

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

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

How do you refer to the problem when talking to your child?
How do you refer to your child's stammer?

REASON FOR REFERRAL

Advice and guidance to support local therapyIndividual therapy at the Michael Palin CentreGroup therapy at the Michael Palin Centre (ages 10 to 18 years)

ADDITIONAL INFORMATION

SPEECH AND LANGUAGE ASSESSMENTS

Please send copies of reports to:

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

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?

YesNo

NAME OF REFERRER

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.

REFERRAL TYPE

PrivateNHS

CHILD OR YOUNG PERSON

First name (required)

Surname (required)

Date of birth (required)

Gender (required)
FemaleMaleOtherPrefer not to say

NHS no. (if known)

Home address (required)

Post code (required)

PARENT 1

First name (required)

Surname (required)

Title [e.g. Mr., Ms., Mrs., Dr., etc.]:

Date of birth (required)

NHS no. (if known)

Home address (if different from above)

Post code

Email address (required)

Telephone number (required)

PARENT 2

First name

Surname

Title [e.g. Mr., Ms., Mrs., Dr., etc.]:

Date of birth

NHS no. (if known)

Home address (if different from above)

Post code

Email address

Telephone number

PARENT 3

First name

Surname

Title [e.g. Mr., Ms., Mrs., Dr., etc.]:

Date of birth

NHS no. (if known)

Home address (if different from above)

Post code

Email address

Telephone number

PARENT 4

First name

Surname

Title [e.g. Mr., Ms., Mrs., Dr., etc.]:

Date of birth

NHS no. (if known)

Home address (if different from above)

Post code

Email address

Telephone number

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

Who has parental responsibility?

Parents' status
TogetherSeparatedDivorced

Would you like to attend together or separately?
TogetherSeparately

Please provide name(s) of other partners to be invited and enter their details in PARENT 2, 3 and/or 4 section

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

YOUR LOCAL NHS TRUST

Name

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

NHS Trust

Email address

When seen (currently or past)

NHS SLT Manager (to be completed by SLT)
Name, address, telephone and email

INDEPENDENT SPEECH AND LANGUAGE THERAPIST

Name

Address

Post code

Telephone number

Email address

When seen (currently or past)

ETHNICITY

Child (required)
White BritishWhite IrishAny other white backgroundWhite & black CaribbeanWhite & black AfricanWhite & AsianAny other mixed backgroundAsian or Asian British - IndianAsian or Asian British - PakistaniAsian or Asian British - BangladeshiAsian or Asian British - any other Asian backgroundBlack or black British – CaribbeanBlack or black British – AfricanBlack or black British – any other backgroundOther Ethnic Groups - ChineseOther Ethnic Groups - any other ethnic groupI would prefer not to say

Parent 1 (required)
White BritishWhite IrishAny other white backgroundWhite & black CaribbeanWhite & black AfricanWhite & AsianAny other mixed backgroundAsian or Asian British - IndianAsian or Asian British - PakistaniAsian or Asian British - BangladeshiAsian or Asian British - any other Asian backgroundBlack or black British – CaribbeanBlack or black British – AfricanBlack or black British – any other backgroundOther Ethnic Groups - ChineseOther Ethnic Groups - any other ethnic groupI would prefer not to say

Parent 2
White BritishWhite IrishAny other white backgroundWhite & black CaribbeanWhite & black AfricanWhite & AsianAny other mixed backgroundAsian or Asian British - IndianAsian or Asian British - PakistaniAsian or Asian British - BangladeshiAsian or Asian British - any other Asian backgroundBlack or black British – CaribbeanBlack or black British – AfricanBlack or black British – any other backgroundOther Ethnic Groups - ChineseOther Ethnic Groups - any other ethnic groupI would prefer not to say

Parent 3
White BritishWhite IrishAny other white backgroundWhite & black CaribbeanWhite & black AfricanWhite & AsianAny other mixed backgroundAsian or Asian British - IndianAsian or Asian British - PakistaniAsian or Asian British - BangladeshiAsian or Asian British - any other Asian backgroundBlack or black British – CaribbeanBlack or black British – AfricanBlack or black British – any other backgroundOther Ethnic Groups - ChineseOther Ethnic Groups - any other ethnic groupI would prefer not to say

Parent 4
White BritishWhite IrishAny other white backgroundWhite & black CaribbeanWhite & black AfricanWhite & AsianAny other mixed backgroundAsian or Asian British - IndianAsian or Asian British - PakistaniAsian or Asian British - BangladeshiAsian or Asian British - any other Asian backgroundBlack or black British – CaribbeanBlack or black British – AfricanBlack or black British – any other backgroundOther Ethnic Groups - ChineseOther Ethnic Groups - any other ethnic groupI would prefer not to say

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

Onset of stammer
Onset of stammer

Has it changed since then?
Has it changed?

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 ideas about why your child started to stammer?

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

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

How do you refer to the problem when talking to your child?
How do you refer to your child's stammer?

REASON FOR REFERRAL

Advice and guidance to support local therapyIndividual therapy at the Michael Palin CentreGroup therapy at the Michael Palin Centre (ages 10 to 18 years)

ADDITIONAL INFORMATION

SPEECH AND LANGUAGE ASSESSMENTS

Please send copies of reports to:

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

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?

YesNo

NAME OF REFERRER

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.

REFERRAL TYPE

PrivateNHS

CHILD OR YOUNG PERSON

First name (required)

Surname (required)

Date of birth (required)

Gender (required)
FemaleMaleOtherPrefer not to say

NHS no. (if known)

Home address (required)

Post code (required)

PARENT 1

First name (required)

Surname (required)

Title [e.g. Mr., Ms., Mrs., Dr., etc.]:

Date of birth (required)

NHS no. (if known)

Home address (if different from above)

Post code

Email address (required)

Telephone number (required)

PARENT 2

First name

Surname

Title [e.g. Mr., Ms., Mrs., Dr., etc.]:

Date of birth

NHS no. (if known)

Home address (if different from above)

Post code

Email address

Telephone number

PARENT 3

First name

Surname

Title [e.g. Mr., Ms., Mrs., Dr., etc.]:

Date of birth

NHS no. (if known)

Home address (if different from above)

Post code

Email address

Telephone number

PARENT 4

First name

Surname

Title [e.g. Mr., Ms., Mrs., Dr., etc.]:

Date of birth

NHS no. (if known)

Home address (if different from above)

Post code

Email address

Telephone number

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

Who has parental responsibility?

Parents' status
TogetherSeparatedDivorced

Would you like to attend together or separately?
TogetherSeparately

Please provide name(s) of other partners to be invited and enter their details in PARENT 2, 3 and/or 4 section

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

YOUR LOCAL NHS TRUST

Name

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

NHS Trust

Email address

When seen (currently or past)

NHS SLT Manager (to be completed by SLT)
Name, address, telephone and email

INDEPENDENT SPEECH AND LANGUAGE THERAPIST

Name

Address

Post code

Telephone number

Email address

When seen (currently or past)

ETHNICITY

Child (required)
White BritishWhite IrishAny other white backgroundWhite & black CaribbeanWhite & black AfricanWhite & AsianAny other mixed backgroundAsian or Asian British - IndianAsian or Asian British - PakistaniAsian or Asian British - BangladeshiAsian or Asian British - any other Asian backgroundBlack or black British – CaribbeanBlack or black British – AfricanBlack or black British – any other backgroundOther Ethnic Groups - ChineseOther Ethnic Groups - any other ethnic groupI would prefer not to say

Parent 1 (required)
White BritishWhite IrishAny other white backgroundWhite & black CaribbeanWhite & black AfricanWhite & AsianAny other mixed backgroundAsian or Asian British - IndianAsian or Asian British - PakistaniAsian or Asian British - BangladeshiAsian or Asian British - any other Asian backgroundBlack or black British – CaribbeanBlack or black British – AfricanBlack or black British – any other backgroundOther Ethnic Groups - ChineseOther Ethnic Groups - any other ethnic groupI would prefer not to say

Parent 2
White BritishWhite IrishAny other white backgroundWhite & black CaribbeanWhite & black AfricanWhite & AsianAny other mixed backgroundAsian or Asian British - IndianAsian or Asian British - PakistaniAsian or Asian British - BangladeshiAsian or Asian British - any other Asian backgroundBlack or black British – CaribbeanBlack or black British – AfricanBlack or black British – any other backgroundOther Ethnic Groups - ChineseOther Ethnic Groups - any other ethnic groupI would prefer not to say

Parent 3
White BritishWhite IrishAny other white backgroundWhite & black CaribbeanWhite & black AfricanWhite & AsianAny other mixed backgroundAsian or Asian British - IndianAsian or Asian British - PakistaniAsian or Asian British - BangladeshiAsian or Asian British - any other Asian backgroundBlack or black British – CaribbeanBlack or black British – AfricanBlack or black British – any other backgroundOther Ethnic Groups - ChineseOther Ethnic Groups - any other ethnic groupI would prefer not to say

Parent 4
White BritishWhite IrishAny other white backgroundWhite & black CaribbeanWhite & black AfricanWhite & AsianAny other mixed backgroundAsian or Asian British - IndianAsian or Asian British - PakistaniAsian or Asian British - BangladeshiAsian or Asian British - any other Asian backgroundBlack or black British – CaribbeanBlack or black British – AfricanBlack or black British – any other backgroundOther Ethnic Groups - ChineseOther Ethnic Groups - any other ethnic groupI would prefer not to say

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

Onset of stammer
Onset of stammer

Has it changed since then?
Has it changed?

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 ideas about why your child started to stammer?

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

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

How do you refer to the problem when talking to your child?
How do you refer to your child's stammer?

REASON FOR REFERRAL

Advice and guidance to support local therapyIndividual therapy at the Michael Palin CentreGroup therapy at the Michael Palin Centre (ages 10 to 18 years)

ADDITIONAL INFORMATION

SPEECH AND LANGUAGE ASSESSMENTS

Please send copies of reports to:

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

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?

YesNo

NAME OF REFERRER

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.

Please fill out as much information as possible. Fields marked * are required

Name (required)

Date of birth (required)

Title MrMrsMsMissDrOther

If "other", please enter your preferred title here:

What would you like to be called by staff at the Centre?

Ethnicity: White BritishWhite IrishAny other white backgroundWhite & black CaribbeanWhite & black AfricanWhite & AsianAny other mixed backgroundAsian or Asian British - IndianAsian or Asian British - PakistaniAsian or Asian British - BangladeshiAsian or Asian British - any other Asian backgroundBlack or black British – CaribbeanBlack or black British – AfricanBlack or black British – any other backgroundOther Ethnic Groups - ChineseOther Ethnic Groups - any other ethnic groupI would prefer not to say

NHS no. (if known)

Home address (required)

Post code (required)

Best phone number to contact you on during the day (required)

Email (required)

Preferred language

Interpreter needed
YesNo

G.P.'s name and address [including postcode] (required)

G.P.'s telephone number

Emergency contact [the name and number of the person we would call in an emergency if you are at the Centre] (required)

Do you see any other professionals for help with anything?
YesNo

If yes, please write down the name of the professional who you see, where you go to see them, and what you see them for.

Do you have any health or mobility issues that we should be aware of?
YesNo

If yes, please write down what these are.

Do you currently take any medication?
YesNo

If yes, please write down what you take and what it is for.

Do you experience any of the following? (tick any that apply)
Low mood or depression: NowIn the pastNeverNot sure
Anxiety unrelated to stammering: NowIn the pastNeverNot sure

Reason for contacting the MPC:

A member of the Michael Palin Centre will contact you by phone or by email within the next 3 weeks to talk about your self-referral and to make an assessment appointment.

Please write down any preferred days or times (during office hours) for staff to contact you.

Name (required)

Date of birth (required)

Title (required)
MrMrsMsMissDrOther

If "other", please enter your preferred title here:

What would you like to be called by staff at the Centre? (required)

Ethnicity (required): White BritishWhite IrishAny other white backgroundWhite & black CaribbeanWhite & black AfricanWhite & AsianAny other mixed backgroundAsian or Asian British - IndianAsian or Asian British - PakistaniAsian or Asian British - BangladeshiAsian or Asian British - any other Asian backgroundBlack or black British – CaribbeanBlack or black British – AfricanBlack or black British – any other backgroundOther Ethnic Groups - ChineseOther Ethnic Groups - any other ethnic groupI would prefer not to say

NHS no. (required)

Home address (required)

Post code (required)

Country (required)

Best phone number to contact you on during the day (required)

Email (required)

Preferred language (required)

Interpreter needed (required)
YesNo

G.P.'s name and address [including postcode] (required)

G.P.'s telephone number (required)

Emergency contact [the name and number of the person we would call in an emergency if you are at the Centre] (required)

Do you see any other professionals for help with anything? (required)
YesNo

If yes, please write down the name of the professional who you see, where you go to see them, and what you see them for.

Do you have any health or mobility issues that we should be aware of? (required)
YesNo

If yes, please write down what these are.

Do you currently take any medication? (required)
YesNo

If yes, please write down what you take and what it is for.

Do you experience any of the following? (tick any that apply)
Low mood or depression: NowIn the pastNeverNot sure
Anxiety unrelated to stammering: NowIn the pastNeverNot sure

Reason for contacting the MPC:

I understand that there is a fee to be seen privately at the Michael Palin Centre at that appointments are made only when payment is received. (required)

A member of the Michael Palin Centre staff will contact you by phone or by email about your self-referral and how to pay for a private assessment.

Please write down any preferred days or times (during office hours) for staff to contact you.