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 was extremely helpful just talking about how I felt about my stammer and different stuff like that.”

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