Referral

Referral

FILL OUT THIS FORM IF YOU WISH TO REFER A CHILD OR YOUNG PERSON TO THE MICHAEL PALIN CENTRE FOR AN ASSESSMENT.

All fields marked as “required” need to be completed for your referral to be accepted.

Please include as much information as possible to enable us to process your referral as quickly as we can.

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.

Referral
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.

“It really helped me to understand what my daughter is thinking and feeling and how I can support her.”