Refer to the MPC

Referrals for children or young people up to 18;11 years

I am a parent (UK resident)

 

You can refer your child to the MPC assessment clinic if:

  • you do not have a local speech and language therapist.
  • there is no local service for children of your child’s age who stammers.
  • you have a local speech and language therapist and you would also like a tertiary, specialist assessment at the MPC.
  • your child’s assessment will be charitably-funded by Action for Stammering Children.

Please complete the form below:

Refer my child (UK resident)

REFERRAL TYPE

CHILD OR YOUNG PERSON

Gender (required)

PARENT 1

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

PARENT 2

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

PARENT 3

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

PARENT 4

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

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)

INDEPENDENT SPEECH AND LANGUAGE THERAPIST

Name

Address

Post code

Telephone number

Email address

When seen (currently or past)

ETHNICITY

Child (required)

Parent 1 (required)

Parent 2

Parent 3

Parent 4

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

Has it changed since then?

When do they stammer more?

When does it happen less?

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?

What does your child do when they stammer?

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

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

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

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

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

Any 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.

If you do not wish to use the online referral form you can also ask your GP to refer your child to the MPC for an assessment.

I am a parent (non-UK resident)

If you are not a UK resident you can refer your child for a private assessment at the MPC assessment clinic. This can be attended in person or by Skype.

Your private assessment will cost £1,200 and payment is required in advance.

There is an additional fee for professional interpreting services if these are required.

Please complete the form below:

Refer my child for a private assessment (non-UK resident)

REFERRAL TYPE

CHILD OR YOUNG PERSON

Gender (required)

PARENT 1

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

PARENT 2

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

PARENT 3

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

PARENT 4

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

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)

INDEPENDENT SPEECH AND LANGUAGE THERAPIST

Name

Address

Post code

Telephone number

Email address

When seen (currently or past)

ETHNICITY

Child (required)

Parent 1 (required)

Parent 2

Parent 3

Parent 4

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

Has it changed since then?

When do they stammer more?

When does it happen less?

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?

What does your child do when they stammer?

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

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

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

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

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

Any 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.

I am a Speech and language therapist (UK)

You can refer a child or young person up to 18;11 years when:

  • you want to confer about the work you are doing with a family and get advice from our specialist team.
  • you feel the family you are working with would be helped by the holistic assessment at the MPC.
  • you think that the family you are working with might be helped by therapy at the MPC.

Please complete the form below:

Refer a child I am working with (SLTs)

REFERRAL TYPE

CHILD OR YOUNG PERSON

Gender (required)

PARENT 1

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

PARENT 2

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

PARENT 3

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

PARENT 4

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

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)

INDEPENDENT SPEECH AND LANGUAGE THERAPIST

Name

Address

Post code

Telephone number

Email address

When seen (currently or past)

ETHNICITY

Child (required)

Parent 1 (required)

Parent 2

Parent 3

Parent 4

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

Has it changed since then?

When do they stammer more?

When does it happen less?

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?

What does your child do when they stammer?

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

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

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

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

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

Any 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.

I am a GP

If there is no local speech and language therapy service then UK-resident families may ask you to refer directly to us for an assessment. Please send your referral, requesting an assessment for a child or young person up to 18;11 years of age to:

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

This assessment for children and young people up to 18;11 years of age will be charitably-funded by Action for Stammering Children.

Referrals for adults

I am an adult living in Camden or Islington

Your assessment will be funded under an agreement that we have with Camden and Islington Commissioners. You can refer yourself by completing the online referral form:

Adult Self-referral form

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:

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.

You can ask your GP to refer you if you do not wish to use the online form. Ask your GP to send the referral letter to:

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

I am an adult living elsewhere in London or the UK

There is a fee of £500 for your assessment at the Centre.

  • ask your GP whether they would be prepared to refer you to the Centre. The referral letter will need to state that they will pay for your assessment, OR
  • refer yourself using the form below if you wish to pay for your assessment privately.We are not able to accept your referral unless we have a written agreement to fund your assessment, either by your GP or by yourself.

Please complete the below form:

Private Adults Self-referral form

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):

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.

THE MICHAEL PALIN CENTER HELPLINE

Sometimes you just need someone to talk to

HELPLINE

Sometimes you just need someone to talk to

Our Helpline, 020 3316 8100, is open during office hours (9am-5pm) and voicemail messages can be left when the office is closed.

“I gained a fantastic grounding in CBT and the interweaving with other therapeutic tools and ways of working with all clients. I came to develop my CBT skills with a voice caseload. Although the course relates to stammering I can see that the skills and knowledge are easily transferable to my caseload.”

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