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Submitted URL: https://cslt.org.uk/
Effective URL: https://referrals.cslt.org.uk/request-for-pediatric-speech-and-language-therapy-service.php
Submission: On July 03 via api from US — Scanned from GB
Effective URL: https://referrals.cslt.org.uk/request-for-pediatric-speech-and-language-therapy-service.php
Submission: On July 03 via api from US — Scanned from GB
Form analysis 1 forms found in the DOM
POST request-for-pediatric-speech-and-language-therapy-service.php
<form method="post" action="request-for-pediatric-speech-and-language-therapy-service.php" enctype="multipart/form-data">
<h4>Referrer (the referrer is the person completing this form)</h4>
<p style="color:red;">PLEASE READ BEFORE COMPLETING THIS FORM.</p>
<p>It is assumed that the person completing this form either is the parent or carer or the person with parental responsibility for the referred child/young person.</p>
<p>If you are not, please ensure that you have sought consent to complete this document on behalf of the person who has parental responsibility.</p>
<p>Please also ensure the section below has your personal details in it – please do not complete the Referrer section with details which are for a company, professional body or the name of the child/young person as this will invalidate the request
for services.</p>
<div class="inputbox">
<div class="c1">Referrer Forename <span style="color:red;">*</span></div>
<div class="c2"><input type="text" name="referrer_firstname" value="" required=""></div>
<div class="clear"></div>
<div class="c1">Referrer Family name <span style="color:red;">*</span></div>
<div class="c2"><input type="text" name="referrer_surname" value="" required=""></div>
<div class="clear"></div>
<div class="c1">Referrer Role or relationship with the child/young person <span style="color:red;">*</span></div>
<div class="c2"><select name="referrer_relationship" class="referrer_relationship" onchange="checkrelationship_referral();" required="">
<option value=""></option>
<option value="Mother">Mother</option>
<option value="Father">Father</option>
<option value="Grandparent">Grandparent</option>
<option value="Foster Parent">Foster Parent</option>
<option value="Legal Guardian">Legal Guardian</option>
<option value="Other">Other</option>
</select>
</div>
<div class="clear"></div>
<script>
function checkrelationship_referral() {
$('.referral_other').hide();
$('.referrer_other_input').prop('required', false);
if ($('.referrer_relationship option:selected').val() == "Other") {
$('.referral_other').show();
$('.referrer_other_input').prop('required', true);
}
}
</script>
<div class="referral_other" style="display:none;">
<div class="c1">Other (please specify)</div>
<div class="c2"><input type="text" name="referrer_other_input" class="referrer_other_input" value=""></div>
<div class="clear"></div>
</div>
<div class="c1">Referrer Contact email <span style="color:red;">*</span></div>
<div class="c2"><input type="text" name="referrer_email" value="" required=""></div>
<div class="clear"></div>
<div class="c1">Referrer Contact telephone number <span style="color:red;">*</span></div>
<div class="c2"><input type="text" name="referrer_telephone" value="" required=""></div>
<div class="clear"></div>
<hr>
<script>
function postcode_lookup4() {
$('#postcode_lookup4').getAddress({
api_key: 'Chcohy-aHk60Ipatk4Kzow27927',
output_fields: {
line_1: '#referrer_address',
line_2: '#referrer_address2',
post_town: '#referrer_town',
county: '#referrer_county',
postcode: '#referrer_postcode'
},
input_label: 'Please start entering address',
input_class: 'find_address_field',
button_label: 'Find Address',
button_class: 'find_address_button'
});
}
$(function() {
postcode_lookup4();
});
</script>
<div class="c1">Find address</div>
<div class="c2">
<div id="postcode_lookup4"><input type="text" id="getaddress_input" value="Please start entering address" class="find_address_field" style="color:#CBCBCB;" name="getaddress_input" autocomplete="off"><button id="getaddress_button" type="button"
class="find_address_button" onclick="return false;">Find Address</button></div>
</div>
<div class="clear"></div>
<hr>
<div class="c1">Referrer Address <span style="color:red;">*</span></div>
<div class="c2"><input type="text" name="referrer_address" id="referrer_address" value="" required=""></div>
<div class="clear"></div>
<div class="c1"> </div>
<div class="c2"><input type="text" name="referrer_address2" id="referrer_address2" value=""></div>
<div class="clear"></div>
<div class="c1">Referrer Town <span style="color:red;">*</span></div>
<div class="c2"><input type="text" name="referrer_town" id="referrer_town" value="" required=""></div>
<div class="clear"></div>
<div class="c1">Referrer County <span style="color:red;">*</span></div>
<div class="c2"><input type="text" name="referrer_county" id="referrer_county" value="" required=""></div>
<div class="clear"></div>
<div class="c1">Referrer Country <span style="color:red;">*</span></div>
<div class="c2"><select name="referrer_country" id="referrer_address" required="">
<option value="GB">United Kingdom</option>
<option value="AF">Afghanistan</option>
<option value="AL">Albania</option>
<option value="DZ">Algeria</option>
<option value="AS">American Samoa</option>
<option value="AD">Andorra</option>
<option value="AO">Angola</option>
<option value="AI">Anguilla</option>
<option value="AQ">Antarctica</option>
<option value="AG">Antigua And Barbuda</option>
<option value="AR">Argentina</option>
<option value="AM">Armenia</option>
<option value="AW">Aruba</option>
<option value="AU">Australia</option>
<option value="AT">Austria</option>
<option value="AZ">Azerbaijan</option>
<option value="BS">Bahamas</option>
<option value="BH">Bahrain</option>
<option value="BD">Bangladesh</option>
<option value="BB">Barbados</option>
<option value="BY">Belarus</option>
<option value="BE">Belgium</option>
<option value="BZ">Belize</option>
<option value="BJ">Benin</option>
<option value="BM">Bermuda</option>
<option value="BT">Bhutan</option>
<option value="BO">Bolivia</option>
<option value="BA">Bosnia And Herzegowina</option>
<option value="BW">Botswana</option>
<option value="BV">Bouvet Island</option>
<option value="BR">Brazil</option>
<option value="IO">British Indian Ocean Territory</option>
<option value="BN">Brunei Darussalam</option>
<option value="BG">Bulgaria</option>
<option value="BF">Burkina Faso</option>
<option value="BI">Burundi</option>
<option value="KH">Cambodia</option>
<option value="CM">Cameroon</option>
<option value="CA">Canada</option>
<option value="CV">Cape Verde</option>
<option value="KY">Cayman Islands</option>
<option value="CF">Central African Republic</option>
<option value="TD">Chad</option>
<option value="CL">Chile</option>
<option value="CN">China</option>
<option value="CX">Christmas Island</option>
<option value="CC">Cocos (Keeling) Islands</option>
<option value="CO">Colombia</option>
<option value="KM">Comoros</option>
<option value="CG">Congo</option>
<option value="CD">Congo, The Democratic Republic Of The</option>
<option value="CK">Cook Islands</option>
<option value="CR">Costa Rica</option>
<option value="HR">Croatia</option>
<option value="CU">Cuba</option>
<option value="CY">Cyprus</option>
<option value="CZ">Czech Republic</option>
<option value="DK">Denmark</option>
<option value="DJ">Djibouti</option>
<option value="DM">Dominica</option>
<option value="DO">Dominican Republic</option>
<option value="TP">East Timor</option>
<option value="EC">Ecuador</option>
<option value="EG">Egypt</option>
<option value="SV">El Salvador</option>
<option value="GQ">Equatorial Guinea</option>
<option value="ER">Eritrea</option>
<option value="EE">Estonia</option>
<option value="ET">Ethiopia</option>
<option value="FK">Falkland Islands (Malvinas)</option>
<option value="FO">Faroe Islands</option>
<option value="FJ">Fiji</option>
<option value="FI">Finland</option>
<option value="FR">France</option>
<option value="FX">France, Metropolitan</option>
<option value="GF">French Guiana</option>
<option value="PF">French Polynesia</option>
<option value="TF">French Southern Territories</option>
<option value="GA">Gabon</option>
<option value="GM">Gambia</option>
<option value="GE">Georgia</option>
<option value="DE">Germany</option>
<option value="GH">Ghana</option>
<option value="GI">Gibraltar</option>
<option value="GR">Greece</option>
<option value="GL">Greenland</option>
<option value="GD">Grenada</option>
<option value="GP">Guadeloupe</option>
<option value="GU">Guam</option>
<option value="GT">Guatemala</option>
<option value="GN">Guinea</option>
<option value="GW">Guinea-Bissau</option>
<option value="GY">Guyana</option>
<option value="HT">Haiti</option>
<option value="HM">Heard And Mc Donald Islands</option>
<option value="VA">Holy See (Vatican City State)</option>
<option value="HN">Honduras</option>
<option value="HK">Hong Kong</option>
<option value="HU">Hungary</option>
<option value="IS">Iceland</option>
<option value="IN">India</option>
<option value="ID">Indonesia</option>
<option value="IR">Iran (Islamic Republic Of)</option>
<option value="IQ">Iraq</option>
<option value="IE">Ireland</option>
<option value="IL">Israel</option>
<option value="IT">Italy</option>
<option value="JM">Jamaica</option>
<option value="JP">Japan</option>
<option value="JO">Jordan</option>
<option value="KZ">Kazakhstan</option>
<option value="KE">Kenya</option>
<option value="KI">Kiribati</option>
<option value="KW">Kuwait</option>
<option value="KG">Kyrgyzstan</option>
<option value="LV">Latvia</option>
<option value="LB">Lebanon</option>
<option value="LS">Lesotho</option>
<option value="LR">Liberia</option>
<option value="LY">Libyan Arab Jamahiriya</option>
<option value="LI">Liechtenstein</option>
<option value="LT">Lithuania</option>
<option value="LU">Luxembourg</option>
<option value="MO">Macau</option>
<option value="MK">Macedonia, Former Yugoslav Republic Of</option>
<option value="MG">Madagascar</option>
<option value="MW">Malawi</option>
<option value="MY">Malaysia</option>
<option value="MV">Maldives</option>
<option value="ML">Mali</option>
<option value="MT">Malta</option>
<option value="MH">Marshall Islands</option>
<option value="MQ">Martinique</option>
<option value="MR">Mauritania</option>
<option value="MU">Mauritius</option>
<option value="YT">Mayotte</option>
<option value="MX">Mexico</option>
<option value="FM">Micronesia, Federated States Of</option>
<option value="MD">Moldova, Republic Of</option>
<option value="MC">Monaco</option>
<option value="MN">Mongolia</option>
<option value="MS">Montserrat</option>
<option value="MA">Morocco</option>
<option value="MZ">Mozambique</option>
<option value="MM">Myanmar</option>
<option value="NA">Namibia</option>
<option value="NR">Nauru</option>
<option value="NP">Nepal</option>
<option value="NL">Netherlands</option>
<option value="AN">Netherlands Antilles</option>
<option value="NC">New Caledonia</option>
<option value="NZ">New Zealand</option>
<option value="NI">Nicaragua</option>
<option value="NE">Niger</option>
<option value="NG">Nigeria</option>
<option value="NU">Niue</option>
<option value="NF">Norfolk Island</option>
<option value="MP">Northern Mariana Islands</option>
<option value="NO">Norway</option>
<option value="OM">Oman</option>
<option value="PK">Pakistan</option>
<option value="PW">Palau</option>
<option value="PA">Panama</option>
<option value="PG">Papua New Guinea</option>
<option value="PY">Paraguay</option>
<option value="PE">Peru</option>
<option value="PH">Philippines</option>
<option value="PN">Pitcairn</option>
<option value="PL">Poland</option>
<option value="PT">Portugal</option>
<option value="PR">Puerto Rico</option>
<option value="QA">Qatar</option>
<option value="RE">Reunion</option>
<option value="RO">Romania</option>
<option value="RU">Russian Federation</option>
<option value="RW">Rwanda</option>
<option value="KN">Saint Kitts And Nevis</option>
<option value="LC">Saint Lucia</option>
<option value="VC">Saint Vincent And The Grenadines</option>
<option value="WS">Samoa</option>
<option value="SM">San Marino</option>
<option value="ST">Sao Tome And Principe</option>
<option value="SA">Saudi Arabia</option>
<option value="SN">Senegal</option>
<option value="SC">Seychelles</option>
<option value="SL">Sierra Leone</option>
<option value="SG">Singapore</option>
<option value="SK">Slovakia</option>
<option value="SI">Slovenia</option>
<option value="SB">Solomon Islands</option>
<option value="SO">Somalia</option>
<option value="ZA">South Africa</option>
<option value="GS">South Georgia, South Sandwich Islands</option>
<option value="KR">South Korea</option>
<option value="ES">Spain</option>
<option value="LK">Sri Lanka</option>
<option value="SH">St. Helena</option>
<option value="PM">St. Pierre And Miquelon</option>
<option value="SD">Sudan</option>
<option value="SR">Suriname</option>
<option value="SJ">Svalbard And Jan Mayen Islands</option>
<option value="SZ">Swaziland</option>
<option value="SE">Sweden</option>
<option value="CH">Switzerland</option>
<option value="SY">Syrian Arab Republic</option>
<option value="TW">Taiwan</option>
<option value="TJ">Tajikistan</option>
<option value="TZ">Tanzania, United Republic Of</option>
<option value="TH">Thailand</option>
<option value="TG">Togo</option>
<option value="TK">Tokelau</option>
<option value="TO">Tonga</option>
<option value="TT">Trinidad And Tobago</option>
<option value="TN">Tunisia</option>
<option value="TR">Turkey</option>
<option value="TM">Turkmenistan</option>
<option value="TC">Turks And Caicos Islands</option>
<option value="TV">Tuvalu</option>
<option value="UG">Uganda</option>
<option value="UA">Ukraine</option>
<option value="AE">United Arab Emirates</option>
<option value="US">United States</option>
<option value="UM">United States Minor Outlying Islands</option>
<option value="UY">Uruguay</option>
<option value="UZ">Uzbekistan</option>
<option value="VU">Vanuatu</option>
<option value="VE">Venezuela</option>
<option value="VN">Viet Nam</option>
<option value="VG">Virgin Islands (British)</option>
<option value="VI">Virgin Islands (U.S.)</option>
<option value="WF">Wallis And Futuna Islands</option>
<option value="EH">Western Sahara</option>
<option value="YE">Yemen</option>
<option value="YU">Yugoslavia</option>
<option value="ZM">Zambia</option>
<option value="ZW">Zimbabwe</option>
</select></div>
<div class="clear"></div>
<div class="c1">Referrer Postcode <span style="color:red;">*</span></div>
<div class="c2"><input type="text" name="referrer_postcode" id="referrer_postcode" value="" required=""></div>
<div class="clear"></div>
</div>
<h4>Consent</h4>
<p>Please remember that you must either be the parent or carer or the person with parental responsibility for the referred child/young person to answer these. If you are not, please ensure that you have sought consent to complete this document on
behalf of the person who has parental responsibility before you proceed. From now on, we will use the term referrer assuming you are one of the above named individuals or someone who has consent to refer. </p>
<div class="inputbox">
<div class="c100">I the referrer, confirm that I either have parental responsibility for or permission from the person/people who do, to complete this Request for Paediatric Speech and Language Therapy (SLT) Services form?<span
style="color:red;">*</span></div>
<div class="clear"></div>
<div class="c100"><select name="parental_consent" class="parental_consent" onchange="checkform();" required="">
<option value=""></option>
<option value="No">No</option>
<option value="Yes">Yes</option>
</select> </div>
<div class="clear"></div>
</div>
<script>
function checkform() {
$('.hideformmessage').hide();
$('.hideform').hide();
if ($('.parental_consent option:selected').val() == "Yes") {
$('.hideform').show();
}
if ($('.parental_consent option:selected').val() == "No") {
$('.hideformmessage').show();
}
}
</script>
<div class="hideformmessage" style="display:none;">
<p style="color:red;text-align:center; font-size:18px;;">We cannot continue with this referral without consent from the relevant individual. Please can we advise that you seek this consent and begin the referral online once again. Thank you, from
the Communicate SLT CIC team</p>
</div>
<div class="hideform">
<div class="inputbox">
<div class="c100">I the referrer, confirm that I either have parental responsibility for or permission from the person/people who do, and that relevant details can be shared by Communicate SLT CIC with other professions involved in the referred
child/young person’s care/education?</div>
<div class="clear"></div>
<div class="c100"><select name="parental_consent_thirdpary" class="parental_consent_thirdpary" required="">
<option value=""></option>
<option value="No">No</option>
<option value="Yes">Yes</option>
</select> </div>
<div class="clear"></div>
</div>
<div class="inputbox">
<p>This question is only for those who are making a request for services for a child/young person who was, at 30 October 2023, on Chatterbug Ltd’s caseload. If you were not, please answer N/A.</p>
<div class="c100">I the referrer, confirm that I either have parental responsibility for or permission from the person/people who do and, if it is required to do so, Communicate SLT have their permission to provide the SLT services their
child/young person requires and to add any data Chatterbug has supplied to a patient record which we will hold?</div>
<div class="clear"></div>
<div class="c100"><select name="chatterbug_caseload" class="chatterbug_caseload" required="">
<option value=""></option>
<option value="No">No</option>
<option value="Yes">Yes</option>
<option value="N/A">N/A</option>
</select> </div>
<div class="clear"></div>
</div>
<div class="inputbox">
<div class="c100">Do Communicate SLT CIC have your permission to contact you in the future with relevant information?</div>
<div class="clear"></div>
<div class="c100"><select name="parental_consent_contact" class="parental_consent_contact" required="">
<option value=""></option>
<option value="No">No</option>
<option value="Yes">Yes</option>
</select> </div>
<div class="clear"></div>
</div>
<h4>Child/young person's details</h4>
<div class="inputbox">
<div class="c1">Child/young person's forename<span style="color:red;">*</span></div>
<div class="c2"><input type="text" name="child_firstname" value="" required=""></div>
<div class="clear"></div>
<div class="c1">Child/young person's family name <span style="color:red;">*</span></div>
<div class="c2"><input type="text" name="child_surname" value="" required=""></div>
<div class="clear"></div>
<div class="c1">Child/young person's date of birth (DOB) <span style="color:red;">*</span></div>
<div class="c2"><input type="text" class="datepicker hasDatepicker" name="dateofbirth" value="" required="" readonly="" id="dp1720015042946"></div>
<div class="clear"></div>
<div class="c1">Child/young person's gender at birth <span style="color:red;">*</span></div>
<div class="c2"><select name="gender" required="">
<option value="" selected="selected" disabled=""></option>
<option value="Male">Male</option>
<option value="Female">Female</option>
</select> </div>
<div class="clear"></div>
<div class="c1">Child/young person's gender identity</div>
<div class="c2"><input type="text" name="gender_identity" value=""></div>
<div class="clear"></div>
<div class="c1">Child/young person's ethnicity</div>
<div class="c2"><select name="ethnicity">
<option value="" selected="selected" disabled=""></option>
<option value="Prefer not to say">Prefer not to say</option>
<option value="Indian">Asian or Asian British - Indian</option>
<option value="Pakistani">Asian or Asian British - Pakistani</option>
<option value="Bangladeshi">Asian or Asian British - Bangladeshi</option>
<option value="Chinese">Asian or Asian British - Chinese</option>
<option value="Other Asian">Asian or Asian British - Any Other Asian Background</option>
<option value="Caribbean">Black, Black British, Caribbean or African - Caribbean</option>
<option value="African">Black, Black British, Caribbean or African - African</option>
<option value="Other Black">Black, Black British, Caribbean or African - Any Other Black, Black British or Caribbean Background</option>
<option value="White and Black Caribbean">Mixed or Multiple Ethnic Groups - White and Black Caribbean</option>
<option value="White and Black African">Mixed or Multiple Ethnic Groups - White and Black African</option>
<option value="White and Asian">Mixed or Multiple Ethnic Groups - White and Asian</option>
<option value="Other Mixed">Mixed or Multiple Ethnic Groups - Any Other Mixed or Multiple Ethnic Background</option>
<option value="British">White - English, Welsh, Scottish, Northern Irish or British</option>
<option value="Irish">White - Irish</option>
<option value="Gypsy">White - Gypsy or Irish Traveller</option>
<option value="Roma">White - Roma</option>
<option value="Other White">White - Any Other White Background</option>
<option value="Arab">Other Ethnic Group - Arab</option>
<option value="Other Ethnic">Other Ethnic Group - Any Other Ethnic Group</option>
</select> </div>
<div class="clear"></div>
<div class="c1">Does the child/young person have an Education, Health and Care Plan (EHCP) in place? <span style="color:red;">*</span></div>
<div class="c2"><select name="ehcp_place" required="">
<option value="" selected="selected" disabled=""></option>
<option value="Yes">Yes</option>
<option value="No">No</option>
</select> </div>
<div class="clear"></div>
</div>
<h4>Parent/carer 1 (main parent/carer)</h4>
<div class="inputbox">
<div class="c1">Parent/carer 1's forename <span style="color:red;">*</span></div>
<div class="c2"><input type="text" name="parent_firstname" value="" required=""></div>
<div class="clear"></div>
<div class="c1">Parent/carer 1's family name <span style="color:red;">*</span></div>
<div class="c2"><input type="text" name="parent_surname" value="" required=""></div>
<div class="clear"></div>
<div class="c1">Parent/carer 1's relationship to the child/young person <span style="color:red;">*</span> </div>
<div class="c2"><select name="relationship_child" required="">
<option value=""></option>
<option value="Mother">Mother</option>
<option value="Father">Father</option>
<option value="Grandparent">Grandparent</option>
<option value="Foster Parent">Foster Parent</option>
<option value="Legal Guardian">Legal Guardian</option>
<option value="Other">Other</option>
</select></div>
<div class="clear"></div>
<div class="c1">Does this person have parental responsibility for the referred child/young person <span style="color:red;">*</span></div>
<div class="c2"><select name="parental_responsibility" class="parental_responsibility" onchange="check_responsible();" required="">
<option value=""></option>
<option value="Yes">Yes</option>
<option value="No">No</option>
</select></div>
<div class="clear"></div>
</div>
<div class="inputbox">
<script>
function postcode_lookupcp() {
$('#postcode_lookupcp').getAddress({
api_key: 'Chcohy-aHk60Ipatk4Kzow27927',
output_fields: {
line_1: '#parent_carers_address1',
line_2: '#parent_carers_address2',
post_town: '#parent_carers_town',
county: '#parent_carers_county',
postcode: '#parent_carers_postcode'
},
input_label: 'Please start entering address',
input_class: 'find_address_field',
button_label: 'Find Address',
button_class: 'find_address_button'
});
}
$(function() {
postcode_lookupcp();
});
</script>
<div class="c1">Find address </div>
<div class="c2">
<div id="postcode_lookupcp"><input type="text" id="getaddress_input" value="Please start entering address" class="find_address_field" style="color:#CBCBCB;" name="getaddress_input" autocomplete="off"><button id="getaddress_button"
type="button" class="find_address_button" onclick="return false;">Find Address</button></div>
</div>
<div class="clear"></div>
<hr>
<div class="c1">Parent/carer 1's home address <span style="color:red;">*</span></div>
<div class="c2"><input type="text" name="parent_carers_address1" id="parent_carers_address1" value="" required=""></div>
<div class="clear"></div>
<div class="c1"> </div>
<div class="c2"><input type="text" name="parent_carers_address2" id="parent_carers_address2" value=""></div>
<div class="clear"></div>
<div class="c1">Parent/carer 1's town <span style="color:red;">*</span></div>
<div class="c2"><input type="text" name="parent_carers_town" id="parent_carers_town" value="" required=""></div>
<div class="clear"></div>
<div class="c1">Parent/carer 1's county <span style="color:red;">*</span></div>
<div class="c2"><input type="text" name="parent_carers_county" id="parent_carers_county" value="" required=""></div>
<div class="clear"></div>
<div class="c1">Parent/carer 1's country <span style="color:red;">*</span></div>
<div class="c2"><select name="parent_carers_country" required="">
<option value="GB">United Kingdom</option>
<option value="AF">Afghanistan</option>
<option value="AL">Albania</option>
<option value="DZ">Algeria</option>
<option value="AS">American Samoa</option>
<option value="AD">Andorra</option>
<option value="AO">Angola</option>
<option value="AI">Anguilla</option>
<option value="AQ">Antarctica</option>
<option value="AG">Antigua And Barbuda</option>
<option value="AR">Argentina</option>
<option value="AM">Armenia</option>
<option value="AW">Aruba</option>
<option value="AU">Australia</option>
<option value="AT">Austria</option>
<option value="AZ">Azerbaijan</option>
<option value="BS">Bahamas</option>
<option value="BH">Bahrain</option>
<option value="BD">Bangladesh</option>
<option value="BB">Barbados</option>
<option value="BY">Belarus</option>
<option value="BE">Belgium</option>
<option value="BZ">Belize</option>
<option value="BJ">Benin</option>
<option value="BM">Bermuda</option>
<option value="BT">Bhutan</option>
<option value="BO">Bolivia</option>
<option value="BA">Bosnia And Herzegowina</option>
<option value="BW">Botswana</option>
<option value="BV">Bouvet Island</option>
<option value="BR">Brazil</option>
<option value="IO">British Indian Ocean Territory</option>
<option value="BN">Brunei Darussalam</option>
<option value="BG">Bulgaria</option>
<option value="BF">Burkina Faso</option>
<option value="BI">Burundi</option>
<option value="KH">Cambodia</option>
<option value="CM">Cameroon</option>
<option value="CA">Canada</option>
<option value="CV">Cape Verde</option>
<option value="KY">Cayman Islands</option>
<option value="CF">Central African Republic</option>
<option value="TD">Chad</option>
<option value="CL">Chile</option>
<option value="CN">China</option>
<option value="CX">Christmas Island</option>
<option value="CC">Cocos (Keeling) Islands</option>
<option value="CO">Colombia</option>
<option value="KM">Comoros</option>
<option value="CG">Congo</option>
<option value="CD">Congo, The Democratic Republic Of The</option>
<option value="CK">Cook Islands</option>
<option value="CR">Costa Rica</option>
<option value="HR">Croatia</option>
<option value="CU">Cuba</option>
<option value="CY">Cyprus</option>
<option value="CZ">Czech Republic</option>
<option value="DK">Denmark</option>
<option value="DJ">Djibouti</option>
<option value="DM">Dominica</option>
<option value="DO">Dominican Republic</option>
<option value="TP">East Timor</option>
<option value="EC">Ecuador</option>
<option value="EG">Egypt</option>
<option value="SV">El Salvador</option>
<option value="GQ">Equatorial Guinea</option>
<option value="ER">Eritrea</option>
<option value="EE">Estonia</option>
<option value="ET">Ethiopia</option>
<option value="FK">Falkland Islands (Malvinas)</option>
<option value="FO">Faroe Islands</option>
<option value="FJ">Fiji</option>
<option value="FI">Finland</option>
<option value="FR">France</option>
<option value="FX">France, Metropolitan</option>
<option value="GF">French Guiana</option>
<option value="PF">French Polynesia</option>
<option value="TF">French Southern Territories</option>
<option value="GA">Gabon</option>
<option value="GM">Gambia</option>
<option value="GE">Georgia</option>
<option value="DE">Germany</option>
<option value="GH">Ghana</option>
<option value="GI">Gibraltar</option>
<option value="GR">Greece</option>
<option value="GL">Greenland</option>
<option value="GD">Grenada</option>
<option value="GP">Guadeloupe</option>
<option value="GU">Guam</option>
<option value="GT">Guatemala</option>
<option value="GN">Guinea</option>
<option value="GW">Guinea-Bissau</option>
<option value="GY">Guyana</option>
<option value="HT">Haiti</option>
<option value="HM">Heard And Mc Donald Islands</option>
<option value="VA">Holy See (Vatican City State)</option>
<option value="HN">Honduras</option>
<option value="HK">Hong Kong</option>
<option value="HU">Hungary</option>
<option value="IS">Iceland</option>
<option value="IN">India</option>
<option value="ID">Indonesia</option>
<option value="IR">Iran (Islamic Republic Of)</option>
<option value="IQ">Iraq</option>
<option value="IE">Ireland</option>
<option value="IL">Israel</option>
<option value="IT">Italy</option>
<option value="JM">Jamaica</option>
<option value="JP">Japan</option>
<option value="JO">Jordan</option>
<option value="KZ">Kazakhstan</option>
<option value="KE">Kenya</option>
<option value="KI">Kiribati</option>
<option value="KW">Kuwait</option>
<option value="KG">Kyrgyzstan</option>
<option value="LV">Latvia</option>
<option value="LB">Lebanon</option>
<option value="LS">Lesotho</option>
<option value="LR">Liberia</option>
<option value="LY">Libyan Arab Jamahiriya</option>
<option value="LI">Liechtenstein</option>
<option value="LT">Lithuania</option>
<option value="LU">Luxembourg</option>
<option value="MO">Macau</option>
<option value="MK">Macedonia, Former Yugoslav Republic Of</option>
<option value="MG">Madagascar</option>
<option value="MW">Malawi</option>
<option value="MY">Malaysia</option>
<option value="MV">Maldives</option>
<option value="ML">Mali</option>
<option value="MT">Malta</option>
<option value="MH">Marshall Islands</option>
<option value="MQ">Martinique</option>
<option value="MR">Mauritania</option>
<option value="MU">Mauritius</option>
<option value="YT">Mayotte</option>
<option value="MX">Mexico</option>
<option value="FM">Micronesia, Federated States Of</option>
<option value="MD">Moldova, Republic Of</option>
<option value="MC">Monaco</option>
<option value="MN">Mongolia</option>
<option value="MS">Montserrat</option>
<option value="MA">Morocco</option>
<option value="MZ">Mozambique</option>
<option value="MM">Myanmar</option>
<option value="NA">Namibia</option>
<option value="NR">Nauru</option>
<option value="NP">Nepal</option>
<option value="NL">Netherlands</option>
<option value="AN">Netherlands Antilles</option>
<option value="NC">New Caledonia</option>
<option value="NZ">New Zealand</option>
<option value="NI">Nicaragua</option>
<option value="NE">Niger</option>
<option value="NG">Nigeria</option>
<option value="NU">Niue</option>
<option value="NF">Norfolk Island</option>
<option value="MP">Northern Mariana Islands</option>
<option value="NO">Norway</option>
<option value="OM">Oman</option>
<option value="PK">Pakistan</option>
<option value="PW">Palau</option>
<option value="PA">Panama</option>
<option value="PG">Papua New Guinea</option>
<option value="PY">Paraguay</option>
<option value="PE">Peru</option>
<option value="PH">Philippines</option>
<option value="PN">Pitcairn</option>
<option value="PL">Poland</option>
<option value="PT">Portugal</option>
<option value="PR">Puerto Rico</option>
<option value="QA">Qatar</option>
<option value="RE">Reunion</option>
<option value="RO">Romania</option>
<option value="RU">Russian Federation</option>
<option value="RW">Rwanda</option>
<option value="KN">Saint Kitts And Nevis</option>
<option value="LC">Saint Lucia</option>
<option value="VC">Saint Vincent And The Grenadines</option>
<option value="WS">Samoa</option>
<option value="SM">San Marino</option>
<option value="ST">Sao Tome And Principe</option>
<option value="SA">Saudi Arabia</option>
<option value="SN">Senegal</option>
<option value="SC">Seychelles</option>
<option value="SL">Sierra Leone</option>
<option value="SG">Singapore</option>
<option value="SK">Slovakia</option>
<option value="SI">Slovenia</option>
<option value="SB">Solomon Islands</option>
<option value="SO">Somalia</option>
<option value="ZA">South Africa</option>
<option value="GS">South Georgia, South Sandwich Islands</option>
<option value="KR">South Korea</option>
<option value="ES">Spain</option>
<option value="LK">Sri Lanka</option>
<option value="SH">St. Helena</option>
<option value="PM">St. Pierre And Miquelon</option>
<option value="SD">Sudan</option>
<option value="SR">Suriname</option>
<option value="SJ">Svalbard And Jan Mayen Islands</option>
<option value="SZ">Swaziland</option>
<option value="SE">Sweden</option>
<option value="CH">Switzerland</option>
<option value="SY">Syrian Arab Republic</option>
<option value="TW">Taiwan</option>
<option value="TJ">Tajikistan</option>
<option value="TZ">Tanzania, United Republic Of</option>
<option value="TH">Thailand</option>
<option value="TG">Togo</option>
<option value="TK">Tokelau</option>
<option value="TO">Tonga</option>
<option value="TT">Trinidad And Tobago</option>
<option value="TN">Tunisia</option>
<option value="TR">Turkey</option>
<option value="TM">Turkmenistan</option>
<option value="TC">Turks And Caicos Islands</option>
<option value="TV">Tuvalu</option>
<option value="UG">Uganda</option>
<option value="UA">Ukraine</option>
<option value="AE">United Arab Emirates</option>
<option value="US">United States</option>
<option value="UM">United States Minor Outlying Islands</option>
<option value="UY">Uruguay</option>
<option value="UZ">Uzbekistan</option>
<option value="VU">Vanuatu</option>
<option value="VE">Venezuela</option>
<option value="VN">Viet Nam</option>
<option value="VG">Virgin Islands (British)</option>
<option value="VI">Virgin Islands (U.S.)</option>
<option value="WF">Wallis And Futuna Islands</option>
<option value="EH">Western Sahara</option>
<option value="YE">Yemen</option>
<option value="YU">Yugoslavia</option>
<option value="ZM">Zambia</option>
<option value="ZW">Zimbabwe</option>
</select></div>
<div class="clear"></div>
<div class="c1">Parent/carer 1's postcode <span style="color:red;">*</span></div>
<div class="c2"><input type="text" name="parent_carers_postcode" id="parent_carers_postcode" value="" required=""></div>
<div class="clear"></div>
<div class="c1">Parent/carer 1's telephone number <span style="color:red;">*</span></div>
<div class="c2"><input type="text" name="parent_telephone" value="" required=""></div>
<div class="clear"></div>
<div class="c1">Parent/carer 1's email address <span style="color:red;">*</span></div>
<div class="c2"><input type="text" name="parent_email" value="" required=""></div>
<div class="clear"></div>
</div>
<h4>Parent/carer 2 (Optional)</h4>
<div class="inputbox">
<div class="c1">Parent/carer 2's forename</div>
<div class="c2"><input type="text" name="parent_firstname2" value=""></div>
<div class="clear"></div>
<div class="c1">Parent/carer 2's family name </div>
<div class="c2"><input type="text" name="parent_surname2" value=""></div>
<div class="clear"></div>
<div class="c1">Parent/carer 2's relationship to the child/young person </div>
<div class="c2"><select name="relationship_child2">
<option value=""></option>
<option value="Mother">Mother</option>
<option value="Father">Father</option>
<option value="Grandparent">Grandparent</option>
<option value="Foster Parent">Foster Parent</option>
<option value="Legal Guardian">Legal Guardian</option>
<option value="Other">Other</option>
</select></div>
<div class="clear"></div>
<div class="c1">Does this person have parental responsibility for the referred child/young person </div>
<div class="c2"><select name="parental_responsibility2" class="parental_responsibility2" onchange="check_responsible();">
<option value=""></option>
<option value="Yes">Yes</option>
<option value="No">No</option>
</select></div>
<div class="clear"></div>
</div>
<div class="inputbox">
<script>
function postcode_lookupcp2() {
$('#postcode_lookupcp2').getAddress({
api_key: 'Chcohy-aHk60Ipatk4Kzow27927',
output_fields: {
line_1: '#parent_carers2_address1',
line_2: '#parent_carers2_address2',
post_town: '#parent_carers2_town',
county: '#parent_carers2_county',
postcode: '#parent_carers2_postcode'
},
input_label: 'Please start entering address',
input_class: 'find_address_field',
button_label: 'Find Address',
button_class: 'find_address_button'
});
}
$(function() {
postcode_lookupcp2();
});
</script>
<div class="c1">Find address </div>
<div class="c2">
<div id="postcode_lookupcp2"><input type="text" id="getaddress_input" value="Please start entering address" class="find_address_field" style="color:#CBCBCB;" name="getaddress_input" autocomplete="off"><button id="getaddress_button"
type="button" class="find_address_button" onclick="return false;">Find Address</button></div>
</div>
<div class="clear"></div>
<hr>
<div class="c1">Parent/carer 2's home address </div>
<div class="c2"><input type="text" name="parent_carers2_address1" id="parent_carers2_address1" value=""></div>
<div class="clear"></div>
<div class="c1"> </div>
<div class="c2"><input type="text" name="parent_carers2_address2" id="parent_carers2_address2" value=""></div>
<div class="clear"></div>
<div class="c1">Parent/carer 2's town </div>
<div class="c2"><input type="text" name="parent_carers2_town" id="parent_carers2_town" value=""></div>
<div class="clear"></div>
<div class="c1">Parent/carer 2's county </div>
<div class="c2"><input type="text" name="parent_carers2_county" id="parent_carers2_county" value=""></div>
<div class="clear"></div>
<div class="c1">Parent/carer 2's country </div>
<div class="c2"><select name="parent_carers2_country">
<option value="GB">United Kingdom</option>
<option value="AF">Afghanistan</option>
<option value="AL">Albania</option>
<option value="DZ">Algeria</option>
<option value="AS">American Samoa</option>
<option value="AD">Andorra</option>
<option value="AO">Angola</option>
<option value="AI">Anguilla</option>
<option value="AQ">Antarctica</option>
<option value="AG">Antigua And Barbuda</option>
<option value="AR">Argentina</option>
<option value="AM">Armenia</option>
<option value="AW">Aruba</option>
<option value="AU">Australia</option>
<option value="AT">Austria</option>
<option value="AZ">Azerbaijan</option>
<option value="BS">Bahamas</option>
<option value="BH">Bahrain</option>
<option value="BD">Bangladesh</option>
<option value="BB">Barbados</option>
<option value="BY">Belarus</option>
<option value="BE">Belgium</option>
<option value="BZ">Belize</option>
<option value="BJ">Benin</option>
<option value="BM">Bermuda</option>
<option value="BT">Bhutan</option>
<option value="BO">Bolivia</option>
<option value="BA">Bosnia And Herzegowina</option>
<option value="BW">Botswana</option>
<option value="BV">Bouvet Island</option>
<option value="BR">Brazil</option>
<option value="IO">British Indian Ocean Territory</option>
<option value="BN">Brunei Darussalam</option>
<option value="BG">Bulgaria</option>
<option value="BF">Burkina Faso</option>
<option value="BI">Burundi</option>
<option value="KH">Cambodia</option>
<option value="CM">Cameroon</option>
<option value="CA">Canada</option>
<option value="CV">Cape Verde</option>
<option value="KY">Cayman Islands</option>
<option value="CF">Central African Republic</option>
<option value="TD">Chad</option>
<option value="CL">Chile</option>
<option value="CN">China</option>
<option value="CX">Christmas Island</option>
<option value="CC">Cocos (Keeling) Islands</option>
<option value="CO">Colombia</option>
<option value="KM">Comoros</option>
<option value="CG">Congo</option>
<option value="CD">Congo, The Democratic Republic Of The</option>
<option value="CK">Cook Islands</option>
<option value="CR">Costa Rica</option>
<option value="HR">Croatia</option>
<option value="CU">Cuba</option>
<option value="CY">Cyprus</option>
<option value="CZ">Czech Republic</option>
<option value="DK">Denmark</option>
<option value="DJ">Djibouti</option>
<option value="DM">Dominica</option>
<option value="DO">Dominican Republic</option>
<option value="TP">East Timor</option>
<option value="EC">Ecuador</option>
<option value="EG">Egypt</option>
<option value="SV">El Salvador</option>
<option value="GQ">Equatorial Guinea</option>
<option value="ER">Eritrea</option>
<option value="EE">Estonia</option>
<option value="ET">Ethiopia</option>
<option value="FK">Falkland Islands (Malvinas)</option>
<option value="FO">Faroe Islands</option>
<option value="FJ">Fiji</option>
<option value="FI">Finland</option>
<option value="FR">France</option>
<option value="FX">France, Metropolitan</option>
<option value="GF">French Guiana</option>
<option value="PF">French Polynesia</option>
<option value="TF">French Southern Territories</option>
<option value="GA">Gabon</option>
<option value="GM">Gambia</option>
<option value="GE">Georgia</option>
<option value="DE">Germany</option>
<option value="GH">Ghana</option>
<option value="GI">Gibraltar</option>
<option value="GR">Greece</option>
<option value="GL">Greenland</option>
<option value="GD">Grenada</option>
<option value="GP">Guadeloupe</option>
<option value="GU">Guam</option>
<option value="GT">Guatemala</option>
<option value="GN">Guinea</option>
<option value="GW">Guinea-Bissau</option>
<option value="GY">Guyana</option>
<option value="HT">Haiti</option>
<option value="HM">Heard And Mc Donald Islands</option>
<option value="VA">Holy See (Vatican City State)</option>
<option value="HN">Honduras</option>
<option value="HK">Hong Kong</option>
<option value="HU">Hungary</option>
<option value="IS">Iceland</option>
<option value="IN">India</option>
<option value="ID">Indonesia</option>
<option value="IR">Iran (Islamic Republic Of)</option>
<option value="IQ">Iraq</option>
<option value="IE">Ireland</option>
<option value="IL">Israel</option>
<option value="IT">Italy</option>
<option value="JM">Jamaica</option>
<option value="JP">Japan</option>
<option value="JO">Jordan</option>
<option value="KZ">Kazakhstan</option>
<option value="KE">Kenya</option>
<option value="KI">Kiribati</option>
<option value="KW">Kuwait</option>
<option value="KG">Kyrgyzstan</option>
<option value="LV">Latvia</option>
<option value="LB">Lebanon</option>
<option value="LS">Lesotho</option>
<option value="LR">Liberia</option>
<option value="LY">Libyan Arab Jamahiriya</option>
<option value="LI">Liechtenstein</option>
<option value="LT">Lithuania</option>
<option value="LU">Luxembourg</option>
<option value="MO">Macau</option>
<option value="MK">Macedonia, Former Yugoslav Republic Of</option>
<option value="MG">Madagascar</option>
<option value="MW">Malawi</option>
<option value="MY">Malaysia</option>
<option value="MV">Maldives</option>
<option value="ML">Mali</option>
<option value="MT">Malta</option>
<option value="MH">Marshall Islands</option>
<option value="MQ">Martinique</option>
<option value="MR">Mauritania</option>
<option value="MU">Mauritius</option>
<option value="YT">Mayotte</option>
<option value="MX">Mexico</option>
<option value="FM">Micronesia, Federated States Of</option>
<option value="MD">Moldova, Republic Of</option>
<option value="MC">Monaco</option>
<option value="MN">Mongolia</option>
<option value="MS">Montserrat</option>
<option value="MA">Morocco</option>
<option value="MZ">Mozambique</option>
<option value="MM">Myanmar</option>
<option value="NA">Namibia</option>
<option value="NR">Nauru</option>
<option value="NP">Nepal</option>
<option value="NL">Netherlands</option>
<option value="AN">Netherlands Antilles</option>
<option value="NC">New Caledonia</option>
<option value="NZ">New Zealand</option>
<option value="NI">Nicaragua</option>
<option value="NE">Niger</option>
<option value="NG">Nigeria</option>
<option value="NU">Niue</option>
<option value="NF">Norfolk Island</option>
<option value="MP">Northern Mariana Islands</option>
<option value="NO">Norway</option>
<option value="OM">Oman</option>
<option value="PK">Pakistan</option>
<option value="PW">Palau</option>
<option value="PA">Panama</option>
<option value="PG">Papua New Guinea</option>
<option value="PY">Paraguay</option>
<option value="PE">Peru</option>
<option value="PH">Philippines</option>
<option value="PN">Pitcairn</option>
<option value="PL">Poland</option>
<option value="PT">Portugal</option>
<option value="PR">Puerto Rico</option>
<option value="QA">Qatar</option>
<option value="RE">Reunion</option>
<option value="RO">Romania</option>
<option value="RU">Russian Federation</option>
<option value="RW">Rwanda</option>
<option value="KN">Saint Kitts And Nevis</option>
<option value="LC">Saint Lucia</option>
<option value="VC">Saint Vincent And The Grenadines</option>
<option value="WS">Samoa</option>
<option value="SM">San Marino</option>
<option value="ST">Sao Tome And Principe</option>
<option value="SA">Saudi Arabia</option>
<option value="SN">Senegal</option>
<option value="SC">Seychelles</option>
<option value="SL">Sierra Leone</option>
<option value="SG">Singapore</option>
<option value="SK">Slovakia</option>
<option value="SI">Slovenia</option>
<option value="SB">Solomon Islands</option>
<option value="SO">Somalia</option>
<option value="ZA">South Africa</option>
<option value="GS">South Georgia, South Sandwich Islands</option>
<option value="KR">South Korea</option>
<option value="ES">Spain</option>
<option value="LK">Sri Lanka</option>
<option value="SH">St. Helena</option>
<option value="PM">St. Pierre And Miquelon</option>
<option value="SD">Sudan</option>
<option value="SR">Suriname</option>
<option value="SJ">Svalbard And Jan Mayen Islands</option>
<option value="SZ">Swaziland</option>
<option value="SE">Sweden</option>
<option value="CH">Switzerland</option>
<option value="SY">Syrian Arab Republic</option>
<option value="TW">Taiwan</option>
<option value="TJ">Tajikistan</option>
<option value="TZ">Tanzania, United Republic Of</option>
<option value="TH">Thailand</option>
<option value="TG">Togo</option>
<option value="TK">Tokelau</option>
<option value="TO">Tonga</option>
<option value="TT">Trinidad And Tobago</option>
<option value="TN">Tunisia</option>
<option value="TR">Turkey</option>
<option value="TM">Turkmenistan</option>
<option value="TC">Turks And Caicos Islands</option>
<option value="TV">Tuvalu</option>
<option value="UG">Uganda</option>
<option value="UA">Ukraine</option>
<option value="AE">United Arab Emirates</option>
<option value="US">United States</option>
<option value="UM">United States Minor Outlying Islands</option>
<option value="UY">Uruguay</option>
<option value="UZ">Uzbekistan</option>
<option value="VU">Vanuatu</option>
<option value="VE">Venezuela</option>
<option value="VN">Viet Nam</option>
<option value="VG">Virgin Islands (British)</option>
<option value="VI">Virgin Islands (U.S.)</option>
<option value="WF">Wallis And Futuna Islands</option>
<option value="EH">Western Sahara</option>
<option value="YE">Yemen</option>
<option value="YU">Yugoslavia</option>
<option value="ZM">Zambia</option>
<option value="ZW">Zimbabwe</option>
</select></div>
<div class="clear"></div>
<div class="c1">Parent/carer 2's postcode </div>
<div class="c2"><input type="text" name="parent_carers2_postcode" id="parent_carers2_postcode" value=""></div>
<div class="clear"></div>
<div class="c1">Parent/carer 2's telephone number</div>
<div class="c2"><input type="text" name="parent2_telephone" value=""></div>
<div class="clear"></div>
<div class="c1">Parent/carer 2's email address </div>
<div class="c2"><input type="text" name="parent2_email" value=""></div>
<div class="clear"></div>
</div>
<script>
function check_responsible() {
$('.check_parent_response').hide();
$('.who_has_parental').prop('required', false);
if ($('.parental_responsibility option:selected').val() == "No") {
if ($('.parental_responsibility2 option:selected').val() == "No" || $('.parental_responsibility2 option:selected').val() == "") {
$('.check_parent_response').show();
$('.who_has_parental').prop('required', true);
}
}
}
</script>
<div class="check_parent_response" style="display:none;">
<div class="inputbox">
<div class="c1">As you have indicated that neither party listed above have parental responsibility, please let us know here who does and their contact details/relationship to the referred child/young person?</div>
<div class="c2"><textarea rows="6" name="who_has_parental" class="who_has_parental"></textarea></div>
<div class="clear"></div>
</div>
</div>
<script>
function childaddresscheck() {
if ($('.child_reside_address option:selected').val() == "Parent/carer 1") {
$('#child_address1').val($('#parent_carers_address1').val());
$('#child_address2').val($('#parent_carers_address2').val());
$('#child_town').val($('#parent_carers_town').val());
$('#child_county').val($('#parent_carers_county').val());
$('#child_postcode').val($('#parent_carers_postcode').val());
} else if ($('.child_reside_address option:selected').val() == "Parent/carer 2") {
$('#child_address1').val($('#parent_carers2_address1').val());
$('#child_address2').val($('#parent_carers2_address2').val());
$('#child_town').val($('#parent_carers2_town').val());
$('#child_county').val($('#parent_carers2_county').val());
$('#child_postcode').val($('#parent_carers2_postcode').val());
} else {
$('#child_address1').val('');
$('#child_address2').val('');
$('#child_town').val('');
$('#child_county').val('');
$('#child_postcode').val('');
}
}
</script>
<h4>Child/young person's address (if different to the above)</h4>
<div class="inputbox">
<div class="c1">Which of the above addresses does the child reside at?</div>
<div class="c2"><select class="child_reside_address" onchange="childaddresscheck();">
<option value=""></option>
<option value="Parent/carer 1">Parent/carer 1</option>
<option value="Parent/carer 2">Parent/carer 2</option>
<option value="Neither">Neither</option>
</select></div>
<div class="clear"></div>
</div>
<div class="inputbox">
<script>
function postcode_lookup3() {
$('#postcode_lookup3').getAddress({
api_key: 'Chcohy-aHk60Ipatk4Kzow27927',
output_fields: {
line_1: '#child_address1',
line_2: '#child_address2',
post_town: '#child_town',
county: '#child_county',
postcode: '#child_postcode'
},
input_label: 'Please start entering address',
input_class: 'find_address_field',
button_label: 'Find Address',
button_class: 'find_address_button'
});
}
$(function() {
postcode_lookup3();
});
</script>
<div class="c1">Find address </div>
<div class="c2">
<div id="postcode_lookup3"><input type="text" id="getaddress_input" value="Please start entering address" class="find_address_field" style="color:#CBCBCB;" name="getaddress_input" autocomplete="off"><button id="getaddress_button"
type="button" class="find_address_button" onclick="return false;">Find Address</button></div>
</div>
<div class="clear"></div>
<hr>
<div class="c1">Child/young person's address <span style="color:red;">*</span></div>
<div class="c2"><input type="text" name="child_address1" id="child_address1" value="" required=""></div>
<div class="clear"></div>
<div class="c1"> </div>
<div class="c2"><input type="text" name="child_address2" id="child_address2" value=""></div>
<div class="clear"></div>
<div class="c1">Child/young person's town <span style="color:red;">*</span></div>
<div class="c2"><input type="text" name="child_town" id="child_town" value="" required=""></div>
<div class="clear"></div>
<div class="c1">Child/young person's county <span style="color:red;">*</span></div>
<div class="c2"><input type="text" name="child_county" id="child_county" value="" required=""></div>
<div class="clear"></div>
<div class="c1">Child/young person's country <span style="color:red;">*</span></div>
<div class="c2"><select name="child_country" required="">
<option value="GB">United Kingdom</option>
<option value="AF">Afghanistan</option>
<option value="AL">Albania</option>
<option value="DZ">Algeria</option>
<option value="AS">American Samoa</option>
<option value="AD">Andorra</option>
<option value="AO">Angola</option>
<option value="AI">Anguilla</option>
<option value="AQ">Antarctica</option>
<option value="AG">Antigua And Barbuda</option>
<option value="AR">Argentina</option>
<option value="AM">Armenia</option>
<option value="AW">Aruba</option>
<option value="AU">Australia</option>
<option value="AT">Austria</option>
<option value="AZ">Azerbaijan</option>
<option value="BS">Bahamas</option>
<option value="BH">Bahrain</option>
<option value="BD">Bangladesh</option>
<option value="BB">Barbados</option>
<option value="BY">Belarus</option>
<option value="BE">Belgium</option>
<option value="BZ">Belize</option>
<option value="BJ">Benin</option>
<option value="BM">Bermuda</option>
<option value="BT">Bhutan</option>
<option value="BO">Bolivia</option>
<option value="BA">Bosnia And Herzegowina</option>
<option value="BW">Botswana</option>
<option value="BV">Bouvet Island</option>
<option value="BR">Brazil</option>
<option value="IO">British Indian Ocean Territory</option>
<option value="BN">Brunei Darussalam</option>
<option value="BG">Bulgaria</option>
<option value="BF">Burkina Faso</option>
<option value="BI">Burundi</option>
<option value="KH">Cambodia</option>
<option value="CM">Cameroon</option>
<option value="CA">Canada</option>
<option value="CV">Cape Verde</option>
<option value="KY">Cayman Islands</option>
<option value="CF">Central African Republic</option>
<option value="TD">Chad</option>
<option value="CL">Chile</option>
<option value="CN">China</option>
<option value="CX">Christmas Island</option>
<option value="CC">Cocos (Keeling) Islands</option>
<option value="CO">Colombia</option>
<option value="KM">Comoros</option>
<option value="CG">Congo</option>
<option value="CD">Congo, The Democratic Republic Of The</option>
<option value="CK">Cook Islands</option>
<option value="CR">Costa Rica</option>
<option value="HR">Croatia</option>
<option value="CU">Cuba</option>
<option value="CY">Cyprus</option>
<option value="CZ">Czech Republic</option>
<option value="DK">Denmark</option>
<option value="DJ">Djibouti</option>
<option value="DM">Dominica</option>
<option value="DO">Dominican Republic</option>
<option value="TP">East Timor</option>
<option value="EC">Ecuador</option>
<option value="EG">Egypt</option>
<option value="SV">El Salvador</option>
<option value="GQ">Equatorial Guinea</option>
<option value="ER">Eritrea</option>
<option value="EE">Estonia</option>
<option value="ET">Ethiopia</option>
<option value="FK">Falkland Islands (Malvinas)</option>
<option value="FO">Faroe Islands</option>
<option value="FJ">Fiji</option>
<option value="FI">Finland</option>
<option value="FR">France</option>
<option value="FX">France, Metropolitan</option>
<option value="GF">French Guiana</option>
<option value="PF">French Polynesia</option>
<option value="TF">French Southern Territories</option>
<option value="GA">Gabon</option>
<option value="GM">Gambia</option>
<option value="GE">Georgia</option>
<option value="DE">Germany</option>
<option value="GH">Ghana</option>
<option value="GI">Gibraltar</option>
<option value="GR">Greece</option>
<option value="GL">Greenland</option>
<option value="GD">Grenada</option>
<option value="GP">Guadeloupe</option>
<option value="GU">Guam</option>
<option value="GT">Guatemala</option>
<option value="GN">Guinea</option>
<option value="GW">Guinea-Bissau</option>
<option value="GY">Guyana</option>
<option value="HT">Haiti</option>
<option value="HM">Heard And Mc Donald Islands</option>
<option value="VA">Holy See (Vatican City State)</option>
<option value="HN">Honduras</option>
<option value="HK">Hong Kong</option>
<option value="HU">Hungary</option>
<option value="IS">Iceland</option>
<option value="IN">India</option>
<option value="ID">Indonesia</option>
<option value="IR">Iran (Islamic Republic Of)</option>
<option value="IQ">Iraq</option>
<option value="IE">Ireland</option>
<option value="IL">Israel</option>
<option value="IT">Italy</option>
<option value="JM">Jamaica</option>
<option value="JP">Japan</option>
<option value="JO">Jordan</option>
<option value="KZ">Kazakhstan</option>
<option value="KE">Kenya</option>
<option value="KI">Kiribati</option>
<option value="KW">Kuwait</option>
<option value="KG">Kyrgyzstan</option>
<option value="LV">Latvia</option>
<option value="LB">Lebanon</option>
<option value="LS">Lesotho</option>
<option value="LR">Liberia</option>
<option value="LY">Libyan Arab Jamahiriya</option>
<option value="LI">Liechtenstein</option>
<option value="LT">Lithuania</option>
<option value="LU">Luxembourg</option>
<option value="MO">Macau</option>
<option value="MK">Macedonia, Former Yugoslav Republic Of</option>
<option value="MG">Madagascar</option>
<option value="MW">Malawi</option>
<option value="MY">Malaysia</option>
<option value="MV">Maldives</option>
<option value="ML">Mali</option>
<option value="MT">Malta</option>
<option value="MH">Marshall Islands</option>
<option value="MQ">Martinique</option>
<option value="MR">Mauritania</option>
<option value="MU">Mauritius</option>
<option value="YT">Mayotte</option>
<option value="MX">Mexico</option>
<option value="FM">Micronesia, Federated States Of</option>
<option value="MD">Moldova, Republic Of</option>
<option value="MC">Monaco</option>
<option value="MN">Mongolia</option>
<option value="MS">Montserrat</option>
<option value="MA">Morocco</option>
<option value="MZ">Mozambique</option>
<option value="MM">Myanmar</option>
<option value="NA">Namibia</option>
<option value="NR">Nauru</option>
<option value="NP">Nepal</option>
<option value="NL">Netherlands</option>
<option value="AN">Netherlands Antilles</option>
<option value="NC">New Caledonia</option>
<option value="NZ">New Zealand</option>
<option value="NI">Nicaragua</option>
<option value="NE">Niger</option>
<option value="NG">Nigeria</option>
<option value="NU">Niue</option>
<option value="NF">Norfolk Island</option>
<option value="MP">Northern Mariana Islands</option>
<option value="NO">Norway</option>
<option value="OM">Oman</option>
<option value="PK">Pakistan</option>
<option value="PW">Palau</option>
<option value="PA">Panama</option>
<option value="PG">Papua New Guinea</option>
<option value="PY">Paraguay</option>
<option value="PE">Peru</option>
<option value="PH">Philippines</option>
<option value="PN">Pitcairn</option>
<option value="PL">Poland</option>
<option value="PT">Portugal</option>
<option value="PR">Puerto Rico</option>
<option value="QA">Qatar</option>
<option value="RE">Reunion</option>
<option value="RO">Romania</option>
<option value="RU">Russian Federation</option>
<option value="RW">Rwanda</option>
<option value="KN">Saint Kitts And Nevis</option>
<option value="LC">Saint Lucia</option>
<option value="VC">Saint Vincent And The Grenadines</option>
<option value="WS">Samoa</option>
<option value="SM">San Marino</option>
<option value="ST">Sao Tome And Principe</option>
<option value="SA">Saudi Arabia</option>
<option value="SN">Senegal</option>
<option value="SC">Seychelles</option>
<option value="SL">Sierra Leone</option>
<option value="SG">Singapore</option>
<option value="SK">Slovakia</option>
<option value="SI">Slovenia</option>
<option value="SB">Solomon Islands</option>
<option value="SO">Somalia</option>
<option value="ZA">South Africa</option>
<option value="GS">South Georgia, South Sandwich Islands</option>
<option value="KR">South Korea</option>
<option value="ES">Spain</option>
<option value="LK">Sri Lanka</option>
<option value="SH">St. Helena</option>
<option value="PM">St. Pierre And Miquelon</option>
<option value="SD">Sudan</option>
<option value="SR">Suriname</option>
<option value="SJ">Svalbard And Jan Mayen Islands</option>
<option value="SZ">Swaziland</option>
<option value="SE">Sweden</option>
<option value="CH">Switzerland</option>
<option value="SY">Syrian Arab Republic</option>
<option value="TW">Taiwan</option>
<option value="TJ">Tajikistan</option>
<option value="TZ">Tanzania, United Republic Of</option>
<option value="TH">Thailand</option>
<option value="TG">Togo</option>
<option value="TK">Tokelau</option>
<option value="TO">Tonga</option>
<option value="TT">Trinidad And Tobago</option>
<option value="TN">Tunisia</option>
<option value="TR">Turkey</option>
<option value="TM">Turkmenistan</option>
<option value="TC">Turks And Caicos Islands</option>
<option value="TV">Tuvalu</option>
<option value="UG">Uganda</option>
<option value="UA">Ukraine</option>
<option value="AE">United Arab Emirates</option>
<option value="US">United States</option>
<option value="UM">United States Minor Outlying Islands</option>
<option value="UY">Uruguay</option>
<option value="UZ">Uzbekistan</option>
<option value="VU">Vanuatu</option>
<option value="VE">Venezuela</option>
<option value="VN">Viet Nam</option>
<option value="VG">Virgin Islands (British)</option>
<option value="VI">Virgin Islands (U.S.)</option>
<option value="WF">Wallis And Futuna Islands</option>
<option value="EH">Western Sahara</option>
<option value="YE">Yemen</option>
<option value="YU">Yugoslavia</option>
<option value="ZM">Zambia</option>
<option value="ZW">Zimbabwe</option>
</select></div>
<div class="clear"></div>
<div class="c1">Child/young person's postcode <span style="color:red;">*</span></div>
<div class="c2"><input type="text" name="child_postcode" id="child_postcode" value="" required=""></div>
<div class="clear"></div>
</div>
<h4>Support with Appointments</h4>
<div class="inputbox">
<div class="c1">If your child/young person has a preferred name, please detail this here. <span style="color:red;">*</span><br> Please be advised that all patient records and correspondence will – unless a legal change of name has occurred at
which point we require paperwork to change this formally – will be in their legal name.<br> We will do our best to refer to your child/young person informally by their preferred name. </div>
<div class="c2"><input type="text" value=""></div>
<div class="clear"></div>
<div class="c1">Is an interpreter needed to converse with parent/carer 1 or the person who has parental responsibility <span style="color:red;">*</span></div>
<div class="c2"><select name="interpreter_needed" required="">
<option value=""></option>
<option value="No">No</option>
<option value="Yes">Yes</option>
</select></div>
<div class="clear"></div>
<div class="c1">If yes, what language should the interpreter speak</div>
<div class="c2"><input type="text" name="lang_interpreter_needed" value=""></div>
<div class="clear"></div>
<div class="c1">Is an interpreter needed to converse with the child/young person? <span style="color:red;">*</span></div>
<div class="c2"><select name="interpreter_young_needed" required="">
<option value=""></option>
<option value="No">No</option>
<option value="Yes">Yes</option>
</select></div>
<div class="clear"></div>
<div class="c1">If yes, what language should the interpreter speak</div>
<div class="c2"><input type="text" name="lang_interpreter_young_needed" value=""></div>
<div class="clear"></div>
<div class="c1">Could the parent/carer or the person who has parental responsibility struggle to read and understand appointment letters written in English? Please be advised if you answer ‘Yes’ to this question, Communicate SLT will assume you
have consent from them for us to send copies of appointment letters to a professional named by the you, to support interaction with us <span style="color:red;">*</span></div>
<div class="c2"><select name="struggle_read" required="">
<option value=""></option>
<option value="No">No</option>
<option value="Yes – I will share details of the named professional when prompted below">Yes – I will share details of the named professional when prompted below</option>
<option value="Not Applicable">Not Applicable</option>
</select></div>
<div class="clear"></div>
<div class="c1">If yes, do you as the referrer confirm the parent/carer consents for copies of appointment letters to be shared with a professional to support attendance? Please provide this professional's name here and ensure that their full
contact details are entered below in the Agencies Involved section.</div>
<div class="c2"><input type="text" name="referral_share_letters" value=""></div>
<div class="clear"></div>
</div>
<h4>Educational setting details</h4>
<div class="inputbox">
<div class="c1">Educational setting type <span style="color:red;">*</span></div>
<div class="c2"><select name="school_name" class="school_name" onchange="checkschool();" required="">
<option value=""></option>
<option value="School">School</option>
<option value="Nursery">Nursery</option>
<option value="Childminder">Childminder</option>
<option value="Home Educated">Home Educated</option>
<option value="Do not attend an educational setting">Do not attend an educational setting – if you choose this option, we do not expect to see an address listed below</option>
</select>
</div>
<div class="clear"></div>
<div class="c1">Educational setting name <span style="color:red;">*</span><br>(If you have answered 'Does not attend an educational setting' in the question above, please share more details here if you can)</div>
<div class="c2"><input type="text" name="school_other" id="school_other" value="" required=""></div>
<div class="clear"></div>
<script>
function checkschool() {
if ($('.school_name option:selected').val() == "Do not attend an educational setting") {
$('#school_address1').prop('required', false);
$('#school_town').prop('required', false);
$('#school_county').prop('required', false);
$('#school_postcode').prop('required', false);
$('#school_other').prop('required', true);
} else {
$('#school_address1').prop('required', true);
$('#school_town').prop('required', true);
$('#school_county').prop('required', true);
$('#school_postcode').prop('required', true);
$('#school_other').prop('required', false);
}
}
function postcode_lookupschool() {
$('#postcode_lookupschool').getAddress({
api_key: 'Chcohy-aHk60Ipatk4Kzow27927',
output_fields: {
line_1: '#school_address1',
line_2: '#school_address2',
post_town: '#school_town',
county: '#school_county',
postcode: '#school_postcode'
},
input_label: 'Please start entering address',
input_class: 'find_address_field',
button_label: 'Find Address',
button_class: 'find_address_button'
});
}
$(function() {
postcode_lookupschool();
});
</script>
<hr>
<div class="c1">Find address</div>
<div class="c2">
<div id="postcode_lookupschool"><input type="text" id="getaddress_input" value="Please start entering address" class="find_address_field" style="color:#CBCBCB;" name="getaddress_input" autocomplete="off"><button id="getaddress_button"
type="button" class="find_address_button" onclick="return false;">Find Address</button></div>
</div>
<div class="clear"></div>
<hr>
<div class="c1">Educational setting address </div>
<div class="c2"><input type="text" name="school_address1" id="school_address1" value="" required=""></div>
<div class="clear"></div>
<div class="c1"> </div>
<div class="c2"><input type="text" name="school_address2" id="school_address2" value=""></div>
<div class="clear"></div>
<div class="c1">Educational setting town </div>
<div class="c2"><input type="text" name="school_town" id="school_town" value="" required=""></div>
<div class="clear"></div>
<div class="c1">Educational setting county </div>
<div class="c2"><input type="text" name="school_county" id="school_county" value="" required=""></div>
<div class="clear"></div>
<div class="c1">Educational setting country</div>
<div class="c2"><select name="school_country">
<option value="GB">United Kingdom</option>
<option value="AF">Afghanistan</option>
<option value="AL">Albania</option>
<option value="DZ">Algeria</option>
<option value="AS">American Samoa</option>
<option value="AD">Andorra</option>
<option value="AO">Angola</option>
<option value="AI">Anguilla</option>
<option value="AQ">Antarctica</option>
<option value="AG">Antigua And Barbuda</option>
<option value="AR">Argentina</option>
<option value="AM">Armenia</option>
<option value="AW">Aruba</option>
<option value="AU">Australia</option>
<option value="AT">Austria</option>
<option value="AZ">Azerbaijan</option>
<option value="BS">Bahamas</option>
<option value="BH">Bahrain</option>
<option value="BD">Bangladesh</option>
<option value="BB">Barbados</option>
<option value="BY">Belarus</option>
<option value="BE">Belgium</option>
<option value="BZ">Belize</option>
<option value="BJ">Benin</option>
<option value="BM">Bermuda</option>
<option value="BT">Bhutan</option>
<option value="BO">Bolivia</option>
<option value="BA">Bosnia And Herzegowina</option>
<option value="BW">Botswana</option>
<option value="BV">Bouvet Island</option>
<option value="BR">Brazil</option>
<option value="IO">British Indian Ocean Territory</option>
<option value="BN">Brunei Darussalam</option>
<option value="BG">Bulgaria</option>
<option value="BF">Burkina Faso</option>
<option value="BI">Burundi</option>
<option value="KH">Cambodia</option>
<option value="CM">Cameroon</option>
<option value="CA">Canada</option>
<option value="CV">Cape Verde</option>
<option value="KY">Cayman Islands</option>
<option value="CF">Central African Republic</option>
<option value="TD">Chad</option>
<option value="CL">Chile</option>
<option value="CN">China</option>
<option value="CX">Christmas Island</option>
<option value="CC">Cocos (Keeling) Islands</option>
<option value="CO">Colombia</option>
<option value="KM">Comoros</option>
<option value="CG">Congo</option>
<option value="CD">Congo, The Democratic Republic Of The</option>
<option value="CK">Cook Islands</option>
<option value="CR">Costa Rica</option>
<option value="HR">Croatia</option>
<option value="CU">Cuba</option>
<option value="CY">Cyprus</option>
<option value="CZ">Czech Republic</option>
<option value="DK">Denmark</option>
<option value="DJ">Djibouti</option>
<option value="DM">Dominica</option>
<option value="DO">Dominican Republic</option>
<option value="TP">East Timor</option>
<option value="EC">Ecuador</option>
<option value="EG">Egypt</option>
<option value="SV">El Salvador</option>
<option value="GQ">Equatorial Guinea</option>
<option value="ER">Eritrea</option>
<option value="EE">Estonia</option>
<option value="ET">Ethiopia</option>
<option value="FK">Falkland Islands (Malvinas)</option>
<option value="FO">Faroe Islands</option>
<option value="FJ">Fiji</option>
<option value="FI">Finland</option>
<option value="FR">France</option>
<option value="FX">France, Metropolitan</option>
<option value="GF">French Guiana</option>
<option value="PF">French Polynesia</option>
<option value="TF">French Southern Territories</option>
<option value="GA">Gabon</option>
<option value="GM">Gambia</option>
<option value="GE">Georgia</option>
<option value="DE">Germany</option>
<option value="GH">Ghana</option>
<option value="GI">Gibraltar</option>
<option value="GR">Greece</option>
<option value="GL">Greenland</option>
<option value="GD">Grenada</option>
<option value="GP">Guadeloupe</option>
<option value="GU">Guam</option>
<option value="GT">Guatemala</option>
<option value="GN">Guinea</option>
<option value="GW">Guinea-Bissau</option>
<option value="GY">Guyana</option>
<option value="HT">Haiti</option>
<option value="HM">Heard And Mc Donald Islands</option>
<option value="VA">Holy See (Vatican City State)</option>
<option value="HN">Honduras</option>
<option value="HK">Hong Kong</option>
<option value="HU">Hungary</option>
<option value="IS">Iceland</option>
<option value="IN">India</option>
<option value="ID">Indonesia</option>
<option value="IR">Iran (Islamic Republic Of)</option>
<option value="IQ">Iraq</option>
<option value="IE">Ireland</option>
<option value="IL">Israel</option>
<option value="IT">Italy</option>
<option value="JM">Jamaica</option>
<option value="JP">Japan</option>
<option value="JO">Jordan</option>
<option value="KZ">Kazakhstan</option>
<option value="KE">Kenya</option>
<option value="KI">Kiribati</option>
<option value="KW">Kuwait</option>
<option value="KG">Kyrgyzstan</option>
<option value="LV">Latvia</option>
<option value="LB">Lebanon</option>
<option value="LS">Lesotho</option>
<option value="LR">Liberia</option>
<option value="LY">Libyan Arab Jamahiriya</option>
<option value="LI">Liechtenstein</option>
<option value="LT">Lithuania</option>
<option value="LU">Luxembourg</option>
<option value="MO">Macau</option>
<option value="MK">Macedonia, Former Yugoslav Republic Of</option>
<option value="MG">Madagascar</option>
<option value="MW">Malawi</option>
<option value="MY">Malaysia</option>
<option value="MV">Maldives</option>
<option value="ML">Mali</option>
<option value="MT">Malta</option>
<option value="MH">Marshall Islands</option>
<option value="MQ">Martinique</option>
<option value="MR">Mauritania</option>
<option value="MU">Mauritius</option>
<option value="YT">Mayotte</option>
<option value="MX">Mexico</option>
<option value="FM">Micronesia, Federated States Of</option>
<option value="MD">Moldova, Republic Of</option>
<option value="MC">Monaco</option>
<option value="MN">Mongolia</option>
<option value="MS">Montserrat</option>
<option value="MA">Morocco</option>
<option value="MZ">Mozambique</option>
<option value="MM">Myanmar</option>
<option value="NA">Namibia</option>
<option value="NR">Nauru</option>
<option value="NP">Nepal</option>
<option value="NL">Netherlands</option>
<option value="AN">Netherlands Antilles</option>
<option value="NC">New Caledonia</option>
<option value="NZ">New Zealand</option>
<option value="NI">Nicaragua</option>
<option value="NE">Niger</option>
<option value="NG">Nigeria</option>
<option value="NU">Niue</option>
<option value="NF">Norfolk Island</option>
<option value="MP">Northern Mariana Islands</option>
<option value="NO">Norway</option>
<option value="OM">Oman</option>
<option value="PK">Pakistan</option>
<option value="PW">Palau</option>
<option value="PA">Panama</option>
<option value="PG">Papua New Guinea</option>
<option value="PY">Paraguay</option>
<option value="PE">Peru</option>
<option value="PH">Philippines</option>
<option value="PN">Pitcairn</option>
<option value="PL">Poland</option>
<option value="PT">Portugal</option>
<option value="PR">Puerto Rico</option>
<option value="QA">Qatar</option>
<option value="RE">Reunion</option>
<option value="RO">Romania</option>
<option value="RU">Russian Federation</option>
<option value="RW">Rwanda</option>
<option value="KN">Saint Kitts And Nevis</option>
<option value="LC">Saint Lucia</option>
<option value="VC">Saint Vincent And The Grenadines</option>
<option value="WS">Samoa</option>
<option value="SM">San Marino</option>
<option value="ST">Sao Tome And Principe</option>
<option value="SA">Saudi Arabia</option>
<option value="SN">Senegal</option>
<option value="SC">Seychelles</option>
<option value="SL">Sierra Leone</option>
<option value="SG">Singapore</option>
<option value="SK">Slovakia</option>
<option value="SI">Slovenia</option>
<option value="SB">Solomon Islands</option>
<option value="SO">Somalia</option>
<option value="ZA">South Africa</option>
<option value="GS">South Georgia, South Sandwich Islands</option>
<option value="KR">South Korea</option>
<option value="ES">Spain</option>
<option value="LK">Sri Lanka</option>
<option value="SH">St. Helena</option>
<option value="PM">St. Pierre And Miquelon</option>
<option value="SD">Sudan</option>
<option value="SR">Suriname</option>
<option value="SJ">Svalbard And Jan Mayen Islands</option>
<option value="SZ">Swaziland</option>
<option value="SE">Sweden</option>
<option value="CH">Switzerland</option>
<option value="SY">Syrian Arab Republic</option>
<option value="TW">Taiwan</option>
<option value="TJ">Tajikistan</option>
<option value="TZ">Tanzania, United Republic Of</option>
<option value="TH">Thailand</option>
<option value="TG">Togo</option>
<option value="TK">Tokelau</option>
<option value="TO">Tonga</option>
<option value="TT">Trinidad And Tobago</option>
<option value="TN">Tunisia</option>
<option value="TR">Turkey</option>
<option value="TM">Turkmenistan</option>
<option value="TC">Turks And Caicos Islands</option>
<option value="TV">Tuvalu</option>
<option value="UG">Uganda</option>
<option value="UA">Ukraine</option>
<option value="AE">United Arab Emirates</option>
<option value="US">United States</option>
<option value="UM">United States Minor Outlying Islands</option>
<option value="UY">Uruguay</option>
<option value="UZ">Uzbekistan</option>
<option value="VU">Vanuatu</option>
<option value="VE">Venezuela</option>
<option value="VN">Viet Nam</option>
<option value="VG">Virgin Islands (British)</option>
<option value="VI">Virgin Islands (U.S.)</option>
<option value="WF">Wallis And Futuna Islands</option>
<option value="EH">Western Sahara</option>
<option value="YE">Yemen</option>
<option value="YU">Yugoslavia</option>
<option value="ZM">Zambia</option>
<option value="ZW">Zimbabwe</option>
</select></div>
<div class="clear"></div>
<div class="c1">Educational setting postcode </div>
<div class="c2"><input type="text" name="school_postcode" id="school_postcode" value="" required=""></div>
<div class="clear"></div>
<div class="c1">Person to contact at educational setting</div>
<div class="c2"><input type="text" name="school_person" value=""></div>
<div class="clear"></div>
<div class="c1">Educational setting email address (if known)</div>
<div class="c2"><input type="text" name="school_email" value=""></div>
<div class="clear"></div>
<div class="c1">Educational setting telephone number (if known)</div>
<div class="c2"><input type="text" name="school_telephone" value=""></div>
<div class="clear"></div>
</div>
<div class="inputbox">
<div class="c1">Year group/class (please enter N/A if this does not apply) <span style="color:red;">*</span></div>
<div class="c2"><input type="text" name="school_year" value="" required=""></div>
<div class="clear"></div>
<div class="c1">What times and days of the week does the referred child/young person usually attend their educational setting?<br><br>Tick all that apply </div>
<div class="c2">
<table>
<tbody>
<tr>
<td><strong>Day</strong></td>
<td><strong>AM</strong></td>
<td><strong>PM</strong></td>
</tr>
<tr>
<td>Monday</td>
<td><input type="checkbox" name="day_mon_am" value="Yes"></td>
<td><input type="checkbox" name="day_mon_pm" value="Yes"></td>
</tr>
<tr>
<td>Tuesday</td>
<td><input type="checkbox" name="day_tue_am" value="Yes"></td>
<td><input type="checkbox" name="day_tue_pm" value="Yes"></td>
</tr>
<tr>
<td>Wednesday</td>
<td><input type="checkbox" name="day_wed_am" value="Yes"></td>
<td><input type="checkbox" name="day_wed_pm" value="Yes"></td>
</tr>
<tr>
<td>Thursday</td>
<td><input type="checkbox" name="day_thu_am" value="Yes"></td>
<td><input type="checkbox" name="day_thu_pm" value="Yes"></td>
</tr>
<tr>
<td>Friday</td>
<td><input type="checkbox" name="day_fri_am" value="Yes"></td>
<td><input type="checkbox" name="day_fri_pm" value="Yes"></td>
</tr>
</tbody>
</table>
</div>
<div class="clear"></div>
<div class="c1">Does the referred child/young person attend the educational setting term time only or all year round? <span style="color:red;">*</span> </div>
<div class="c2"><select name="attend_setting_type" required="">
<option value=""></option>
<option value="Term Time Only">Term Time Only</option>
<option value="All Year Round">All Year Round</option>
</select></div>
<div class="clear"></div>
</div>
<h4>Existing family support</h4>
<div class="inputbox">
<div class="c1">Is there a Multi-Agency Plan (MAP), Early Help Assessment (EHA) or Early Help Plan (EHP) in place? <span style="color:red;">*</span></div>
<div class="c2"><select name="caf" required="">
<option value="" selected="selected" disabled=""></option>
<option value="Yes">Yes</option>
<option value="No">No</option>
</select> </div>
<div class="clear"></div>
<div class="c1">Is there a child/young person protection plan in place? <span style="color:red;">*</span></div>
<div class="c2"><select name="protection_plan" required="">
<option value="" selected="selected" disabled=""></option>
<option value="Yes">Yes</option>
<option value="No">No</option>
</select> </div>
<div class="clear"></div>
<div class="c1">Is there a child/young person in need plan in place? <span style="color:red;">*</span></div>
<div class="c2"><select name="child_in_need" required="">
<option value="" selected="selected" disabled=""></option>
<option value="Yes">Yes</option>
<option value="No">No</option>
</select> </div>
<div class="clear"></div>
<div class="c1">Is the child/young person in the care of the Local Authority? <span style="color:red;">*</span></div>
<div class="c2"><select name="local_authority" required="">
<option value="" selected="selected" disabled=""></option>
<option value="Yes">Yes</option>
<option value="No">No</option>
</select> </div>
<div class="clear"></div>
</div>
<h4>Existing diagnoses</h4>
<div class="inputbox">
<h4>Does the child/young person have a current diagnosis of any of the following</h4>
<p>Please share details of anything else you feel might be relevant from the child/young person’s medical history and let us know what medication and/or physical and/or mental health support is already in place. You may wish to share with us
information around vision tests, hearing tests, allergies, physical needs for example. </p>
<div class="c1">ADHD <span style="color:red;">*</span></div>
<div class="c2"><select name="diagnosis_adhd" required="">
<option value=""></option>
<option value="No">No</option>
<option value="Yes">Yes</option>
<option value="Don't Know">Don't Know</option>
</select> </div>
<div class="clear"></div>
<div class="c1">Autism <span style="color:red;">*</span></div>
<div class="c2"><select name="diagnosis_autism" required="">
<option value=""></option>
<option value="No">No</option>
<option value="Yes">Yes</option>
<option value="Don't Know">Don't Know</option>
</select> </div>
<div class="clear"></div>
<div class="c1">Cerebral Palsy <span style="color:red;">*</span></div>
<div class="c2"><select name="diagnosis_cerebral_palsy" required="">
<option value=""></option>
<option value="No">No</option>
<option value="Yes">Yes</option>
<option value="Don't Know">Don't Know</option>
</select> </div>
<div class="clear"></div>
<div class="c1">Cleft Lip and Palate <span style="color:red;">*</span></div>
<div class="c2"><select name="diagnosis_cleft_lip" required="">
<option value=""></option>
<option value="No">No</option>
<option value="Yes">Yes</option>
<option value="Don't Know">Don't Know</option>
</select> </div>
<div class="clear"></div>
<div class="c1">Hearing Impairment <span style="color:red;">*</span></div>
<div class="c2"><select name="diagnosis_hearing" required="">
<option value=""></option>
<option value="No">No</option>
<option value="Yes">Yes</option>
<option value="Don't Know">Don't Know</option>
</select> </div>
<div class="clear"></div>
<div class="c1">Learning Disability <span style="color:red;">*</span></div>
<div class="c2"><select name="diagnosis_learning" required="">
<option value=""></option>
<option value="No">No</option>
<option value="Yes">Yes</option>
<option value="Don't Know">Don't Know</option>
</select> </div>
<div class="clear"></div>
<div class="c1">Selective Mutism <span style="color:red;">*</span></div>
<div class="c2"><select name="diagnosis_mutism" required="">
<option value=""></option>
<option value="No">No</option>
<option value="Yes">Yes</option>
<option value="Don't Know">Don't Know</option>
</select> </div>
<div class="clear"></div>
<div class="c1">Social, Emotional and Mental Health Needs (SEMH Needs) <span style="color:red;">*</span></div>
<div class="c2"><select name="diagnosis_semh_needs" required="">
<option value=""></option>
<option value="No">No</option>
<option value="Yes">Yes</option>
<option value="Don't Know">Don't Know</option>
</select> </div>
<div class="clear"></div>
<div class="c1">Other</div>
<div class="c2"><input type="text" name="diagnosis_other" value=""></div>
<div class="clear"></div>
</div>
<div class="inputbox">
<div class="c100">Please share any other relevant medical history and support/medication in place<br> (e.g. recent hearing, vision test, allergies, epilepsy, mental health, physical needs, other)</div>
<div class="clear"></div>
<br>
<div class="c1">Details</div>
<div class="c2"><textarea rows="6" name="medical_history"></textarea></div>
<div class="clear"></div>
</div>
<h4>Existing agencies involved</h4>
<div class="inputbox">
<div class="c1">GP practice name</div>
<div class="c2"><input type="text" name="gp_practice" value=""></div>
<div class="clear"></div>
<script>
function postcode_lookupgp() {
$('#postcode_lookupgp').getAddress({
api_key: 'Chcohy-aHk60Ipatk4Kzow27927',
output_fields: {
line_1: '#gp_address1',
line_2: '#gp_address2',
post_town: '#gp_town',
county: '#gp_county',
postcode: '#gp_postcode'
},
input_label: 'Please start entering address',
input_class: 'find_address_field',
button_label: 'Find Address',
button_class: 'find_address_button'
});
}
$(function() {
postcode_lookupgp();
});
</script>
<hr>
<div class="c1">Find address</div>
<div class="c2">
<div id="postcode_lookupgp"><input type="text" id="getaddress_input" value="Please start entering address" class="find_address_field" style="color:#CBCBCB;" name="getaddress_input" autocomplete="off"><button id="getaddress_button"
type="button" class="find_address_button" onclick="return false;">Find Address</button></div>
</div>
<div class="clear"></div>
<hr>
<div class="c1">GP address <span style="color:red;">*</span></div>
<div class="c2"><input type="text" name="gp_address1" id="gp_address1" value="" required=""></div>
<div class="clear"></div>
<div class="c1"> </div>
<div class="c2"><input type="text" name="gp_address2" id="gp_address2" value=""></div>
<div class="clear"></div>
<div class="c1">GP town <span style="color:red;">*</span></div>
<div class="c2"><input type="text" name="gp_town" id="gp_town" value="" required=""></div>
<div class="clear"></div>
<div class="c1">GP county <span style="color:red;">*</span></div>
<div class="c2"><input type="text" name="gp_county" id="gp_county" value="" required=""></div>
<div class="clear"></div>
<div class="c1">GP country <span style="color:red;">*</span></div>
<div class="c2"><select name="gp_country" required="">
<option value="GB">United Kingdom</option>
<option value="AF">Afghanistan</option>
<option value="AL">Albania</option>
<option value="DZ">Algeria</option>
<option value="AS">American Samoa</option>
<option value="AD">Andorra</option>
<option value="AO">Angola</option>
<option value="AI">Anguilla</option>
<option value="AQ">Antarctica</option>
<option value="AG">Antigua And Barbuda</option>
<option value="AR">Argentina</option>
<option value="AM">Armenia</option>
<option value="AW">Aruba</option>
<option value="AU">Australia</option>
<option value="AT">Austria</option>
<option value="AZ">Azerbaijan</option>
<option value="BS">Bahamas</option>
<option value="BH">Bahrain</option>
<option value="BD">Bangladesh</option>
<option value="BB">Barbados</option>
<option value="BY">Belarus</option>
<option value="BE">Belgium</option>
<option value="BZ">Belize</option>
<option value="BJ">Benin</option>
<option value="BM">Bermuda</option>
<option value="BT">Bhutan</option>
<option value="BO">Bolivia</option>
<option value="BA">Bosnia And Herzegowina</option>
<option value="BW">Botswana</option>
<option value="BV">Bouvet Island</option>
<option value="BR">Brazil</option>
<option value="IO">British Indian Ocean Territory</option>
<option value="BN">Brunei Darussalam</option>
<option value="BG">Bulgaria</option>
<option value="BF">Burkina Faso</option>
<option value="BI">Burundi</option>
<option value="KH">Cambodia</option>
<option value="CM">Cameroon</option>
<option value="CA">Canada</option>
<option value="CV">Cape Verde</option>
<option value="KY">Cayman Islands</option>
<option value="CF">Central African Republic</option>
<option value="TD">Chad</option>
<option value="CL">Chile</option>
<option value="CN">China</option>
<option value="CX">Christmas Island</option>
<option value="CC">Cocos (Keeling) Islands</option>
<option value="CO">Colombia</option>
<option value="KM">Comoros</option>
<option value="CG">Congo</option>
<option value="CD">Congo, The Democratic Republic Of The</option>
<option value="CK">Cook Islands</option>
<option value="CR">Costa Rica</option>
<option value="HR">Croatia</option>
<option value="CU">Cuba</option>
<option value="CY">Cyprus</option>
<option value="CZ">Czech Republic</option>
<option value="DK">Denmark</option>
<option value="DJ">Djibouti</option>
<option value="DM">Dominica</option>
<option value="DO">Dominican Republic</option>
<option value="TP">East Timor</option>
<option value="EC">Ecuador</option>
<option value="EG">Egypt</option>
<option value="SV">El Salvador</option>
<option value="GQ">Equatorial Guinea</option>
<option value="ER">Eritrea</option>
<option value="EE">Estonia</option>
<option value="ET">Ethiopia</option>
<option value="FK">Falkland Islands (Malvinas)</option>
<option value="FO">Faroe Islands</option>
<option value="FJ">Fiji</option>
<option value="FI">Finland</option>
<option value="FR">France</option>
<option value="FX">France, Metropolitan</option>
<option value="GF">French Guiana</option>
<option value="PF">French Polynesia</option>
<option value="TF">French Southern Territories</option>
<option value="GA">Gabon</option>
<option value="GM">Gambia</option>
<option value="GE">Georgia</option>
<option value="DE">Germany</option>
<option value="GH">Ghana</option>
<option value="GI">Gibraltar</option>
<option value="GR">Greece</option>
<option value="GL">Greenland</option>
<option value="GD">Grenada</option>
<option value="GP">Guadeloupe</option>
<option value="GU">Guam</option>
<option value="GT">Guatemala</option>
<option value="GN">Guinea</option>
<option value="GW">Guinea-Bissau</option>
<option value="GY">Guyana</option>
<option value="HT">Haiti</option>
<option value="HM">Heard And Mc Donald Islands</option>
<option value="VA">Holy See (Vatican City State)</option>
<option value="HN">Honduras</option>
<option value="HK">Hong Kong</option>
<option value="HU">Hungary</option>
<option value="IS">Iceland</option>
<option value="IN">India</option>
<option value="ID">Indonesia</option>
<option value="IR">Iran (Islamic Republic Of)</option>
<option value="IQ">Iraq</option>
<option value="IE">Ireland</option>
<option value="IL">Israel</option>
<option value="IT">Italy</option>
<option value="JM">Jamaica</option>
<option value="JP">Japan</option>
<option value="JO">Jordan</option>
<option value="KZ">Kazakhstan</option>
<option value="KE">Kenya</option>
<option value="KI">Kiribati</option>
<option value="KW">Kuwait</option>
<option value="KG">Kyrgyzstan</option>
<option value="LV">Latvia</option>
<option value="LB">Lebanon</option>
<option value="LS">Lesotho</option>
<option value="LR">Liberia</option>
<option value="LY">Libyan Arab Jamahiriya</option>
<option value="LI">Liechtenstein</option>
<option value="LT">Lithuania</option>
<option value="LU">Luxembourg</option>
<option value="MO">Macau</option>
<option value="MK">Macedonia, Former Yugoslav Republic Of</option>
<option value="MG">Madagascar</option>
<option value="MW">Malawi</option>
<option value="MY">Malaysia</option>
<option value="MV">Maldives</option>
<option value="ML">Mali</option>
<option value="MT">Malta</option>
<option value="MH">Marshall Islands</option>
<option value="MQ">Martinique</option>
<option value="MR">Mauritania</option>
<option value="MU">Mauritius</option>
<option value="YT">Mayotte</option>
<option value="MX">Mexico</option>
<option value="FM">Micronesia, Federated States Of</option>
<option value="MD">Moldova, Republic Of</option>
<option value="MC">Monaco</option>
<option value="MN">Mongolia</option>
<option value="MS">Montserrat</option>
<option value="MA">Morocco</option>
<option value="MZ">Mozambique</option>
<option value="MM">Myanmar</option>
<option value="NA">Namibia</option>
<option value="NR">Nauru</option>
<option value="NP">Nepal</option>
<option value="NL">Netherlands</option>
<option value="AN">Netherlands Antilles</option>
<option value="NC">New Caledonia</option>
<option value="NZ">New Zealand</option>
<option value="NI">Nicaragua</option>
<option value="NE">Niger</option>
<option value="NG">Nigeria</option>
<option value="NU">Niue</option>
<option value="NF">Norfolk Island</option>
<option value="MP">Northern Mariana Islands</option>
<option value="NO">Norway</option>
<option value="OM">Oman</option>
<option value="PK">Pakistan</option>
<option value="PW">Palau</option>
<option value="PA">Panama</option>
<option value="PG">Papua New Guinea</option>
<option value="PY">Paraguay</option>
<option value="PE">Peru</option>
<option value="PH">Philippines</option>
<option value="PN">Pitcairn</option>
<option value="PL">Poland</option>
<option value="PT">Portugal</option>
<option value="PR">Puerto Rico</option>
<option value="QA">Qatar</option>
<option value="RE">Reunion</option>
<option value="RO">Romania</option>
<option value="RU">Russian Federation</option>
<option value="RW">Rwanda</option>
<option value="KN">Saint Kitts And Nevis</option>
<option value="LC">Saint Lucia</option>
<option value="VC">Saint Vincent And The Grenadines</option>
<option value="WS">Samoa</option>
<option value="SM">San Marino</option>
<option value="ST">Sao Tome And Principe</option>
<option value="SA">Saudi Arabia</option>
<option value="SN">Senegal</option>
<option value="SC">Seychelles</option>
<option value="SL">Sierra Leone</option>
<option value="SG">Singapore</option>
<option value="SK">Slovakia</option>
<option value="SI">Slovenia</option>
<option value="SB">Solomon Islands</option>
<option value="SO">Somalia</option>
<option value="ZA">South Africa</option>
<option value="GS">South Georgia, South Sandwich Islands</option>
<option value="KR">South Korea</option>
<option value="ES">Spain</option>
<option value="LK">Sri Lanka</option>
<option value="SH">St. Helena</option>
<option value="PM">St. Pierre And Miquelon</option>
<option value="SD">Sudan</option>
<option value="SR">Suriname</option>
<option value="SJ">Svalbard And Jan Mayen Islands</option>
<option value="SZ">Swaziland</option>
<option value="SE">Sweden</option>
<option value="CH">Switzerland</option>
<option value="SY">Syrian Arab Republic</option>
<option value="TW">Taiwan</option>
<option value="TJ">Tajikistan</option>
<option value="TZ">Tanzania, United Republic Of</option>
<option value="TH">Thailand</option>
<option value="TG">Togo</option>
<option value="TK">Tokelau</option>
<option value="TO">Tonga</option>
<option value="TT">Trinidad And Tobago</option>
<option value="TN">Tunisia</option>
<option value="TR">Turkey</option>
<option value="TM">Turkmenistan</option>
<option value="TC">Turks And Caicos Islands</option>
<option value="TV">Tuvalu</option>
<option value="UG">Uganda</option>
<option value="UA">Ukraine</option>
<option value="AE">United Arab Emirates</option>
<option value="US">United States</option>
<option value="UM">United States Minor Outlying Islands</option>
<option value="UY">Uruguay</option>
<option value="UZ">Uzbekistan</option>
<option value="VU">Vanuatu</option>
<option value="VE">Venezuela</option>
<option value="VN">Viet Nam</option>
<option value="VG">Virgin Islands (British)</option>
<option value="VI">Virgin Islands (U.S.)</option>
<option value="WF">Wallis And Futuna Islands</option>
<option value="EH">Western Sahara</option>
<option value="YE">Yemen</option>
<option value="YU">Yugoslavia</option>
<option value="ZM">Zambia</option>
<option value="ZW">Zimbabwe</option>
</select></div>
<div class="clear"></div>
<div class="c1">GP postcode <span style="color:red;">*</span></div>
<div class="c2"><input type="text" name="gp_postcode" id="gp_postcode" value="" required=""></div>
<div class="clear"></div>
</div>
<div class="inputbox">
<div class="c1" style="padding-top:15px;">Speech and Language Therapy <span style="color:red;">*</span></div>
<div class="c2"><select name="agencies_speech" required="">
<option value=""></option>
<option value="No">No</option>
<option value="Yes">Yes</option>
</select> </div>
<div class="clear"></div>
<div class="c1">If yes, please provide the Therapist's name and contact details</div>
<div class="c2"><input type="text" name="agencies_speech_details" value=""></div>
<div class="clear"></div>
<div class="c1" style="padding-top:15px;">Occupational Therapy <span style="color:red;">*</span></div>
<div class="c2"><select name="agencies_occupational" required="">
<option value=""></option>
<option value="No">No</option>
<option value="Yes">Yes</option>
</select> </div>
<div class="clear"></div>
<div class="c1">If yes, please provide the Therapist's name and contact details <span style="color:red;">*</span></div>
<div class="c2"><input type="text" name="agencies_occupational_details" value=""></div>
<div class="clear"></div>
<div class="c1" style="padding-top:15px;">Physiotherapy <span style="color:red;">*</span></div>
<div class="c2"><select name="agencies_physiotherapy" required="">
<option value=""></option>
<option value="No">No</option>
<option value="Yes">Yes</option>
</select> </div>
<div class="clear"></div>
<div class="c1">If yes, please provide the Therapist's name and contact details</div>
<div class="c2"><input type="text" name="agencies_physiotherapy_details" value=""></div>
<div class="clear"></div>
<div class="c1" style="padding-top:15px;">Paediatrician <span style="color:red;">*</span></div>
<div class="c2"><select name="agencies_paediatrician" required="">
<option value=""></option>
<option value="No">No</option>
<option value="Yes">Yes</option>
</select> </div>
<div class="clear"></div>
<div class="c1">If yes, please provide the Paediatrician's name and contact details</div>
<div class="c2"><input type="text" name="agencies_paediatrician_details" value=""></div>
<div class="clear"></div>
<div class="c1" style="padding-top:15px;">Social Services <span style="color:red;">*</span></div>
<div class="c2"><select name="agencies_social" required="">
<option value=""></option>
<option value="No">No</option>
<option value="Yes">Yes</option>
</select> </div>
<div class="clear"></div>
<div class="c1">If yes, please provide the name of your contact at Social Services and their contact details</div>
<div class="c2"><input type="text" name="agencies_social_details" value=""></div>
<div class="clear"></div>
<div class="c1" style="padding-top:15px;">Advisory Teachers <span style="color:red;">*</span></div>
<div class="c2"><select name="agencies_advisory" required="">
<option value=""></option>
<option value="No">No</option>
<option value="Yes">Yes</option>
</select> </div>
<div class="clear"></div>
<div class="c1">If yes, please provide the Teacher's name and contact details</div>
<div class="c2"><input type="text" name="agencies_advisory_details" value=""></div>
<div class="clear"></div>
<div class="c1" style="padding-top:15px;">Education Psychology <span style="color:red;">*</span></div>
<div class="c2"><select name="agencies_psychology" required="">
<option value=""></option>
<option value="No">No</option>
<option value="Yes">Yes</option>
</select> </div>
<div class="clear"></div>
<div class="c1">If yes, please provide the Psychologist's name and contact details</div>
<div class="c2"><input type="text" name="agencies_psychology_details" value=""></div>
<div class="clear"></div>
<div class="c1" style="padding-top:15px;">CAMHS <span style="color:red;">*</span></div>
<div class="c2"><select name="agencies_camhs" required="">
<option value=""></option>
<option value="No">No</option>
<option value="Yes">Yes</option>
</select> </div>
<div class="clear"></div>
<div class="c1">If yes, please provide details of the CAMHS service supporting the child/young person</div>
<div class="c2"><input type="text" name="agencies_camhs_details" value=""></div>
<div class="clear"></div>
<div class="c1">Has the Special Educational Needs Co-Ordinator (SENCo) in an educational setting been informed of this referral? <span style="color:red;">*</span></div>
<div class="c2"><select name="education_senco" required="">
<option value=""></option>
<option value="No">No</option>
<option value="Yes">Yes</option>
</select> </div>
<div class="clear"></div>
<div class="c1">Other – please give as much detail as possible, including the name, profession and postal address of the professional to whom you require Communicate SLT to send copies of appointments to, should you have indicated a language
barrier earlier in this referral. </div>
<div class="c2"><textarea rows="6" name="agencies_other"></textarea></div>
<div class="clear"></div>
</div>
<div class="inputbox">
<div class="c1">Has this child/young person been referred to speech and language therapy services previously? <span style="color:red;">*</span></div>
<div class="c2"><select name="previous_speech" required="">
<option value="" selected="selected" disabled=""></option>
<option value="No">No</option>
<option value="Yes">Yes</option>
<option value="Don't Know">Don't Know</option>
</select> </div>
<div class="clear"></div>
<div class="c1">If you have answered yes or don’t know, please provide as much detail as you can here. You may be able to advise who the therapy provider was, when the therapy took place, what practices you were asked to put in place for
example.</div>
<div class="c2"><textarea rows="6" name="previous_other_speech"></textarea></div>
<div class="clear"></div>
</div>
<h4>Areas of Concern</h4>
<p>What is your main area of concern? (Score 0 for no concerns at all and 5 for severe difficulties in this area)</p>
<div class="inputbox">
<div class="c1">Attention and Listening <span style="color:red;">*</span><br>e.g. poor concentration, highly distractable, not able to focus on adult led activities for an age appropriate length of time</div>
<div class="c2"><select name="skills_attention" required="">
<option value="" selected="selected" disabled=""></option>
<option value="0">0</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
<option value="5">5</option>
</select> </div>
<div class="clear"></div>
<div class="c1">Understanding Language <span style="color:red;">*</span><br>e.g. not able to follow instructions, answer questions, or understand concepts at an age appropriate level</div>
<div class="c2"><select name="skills_understanding" required="">
<option value="" selected="selected" disabled=""></option>
<option value="0">0</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
<option value="5">5</option>
</select> </div>
<div class="clear"></div>
<div class="c1">Expressive Language (talking) <span style="color:red;">*</span><br>e.g. limited vocabulary development, difficulties using age appropriate spoken grammar/sentence structure, word finding difficulties</div>
<div class="c2"><select name="skills_expressive" required="">
<option value="" selected="selected" disabled=""></option>
<option value="0">0</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
<option value="5">5</option>
</select> </div>
<div class="clear"></div>
<div class="c1">Speech/Articulation <span style="color:red;">*</span><br>e.g. unclear speech, incorrect or limited speech sounds used</div>
<div class="c2"><select name="skills_speech" required="">
<option value="" selected="selected" disabled=""></option>
<option value="0">0</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
<option value="5">5</option>
</select> </div>
<div class="clear"></div>
<div class="c1">Social Skills <span style="color:red;">*</span><br>e.g. difficulties with turn taking, keeping to topic, literal interpretation of language, limited awareness of other children/adults, difficulties with friendships</div>
<div class="c2"><select name="skills_social" required="">
<option value="" selected="selected" disabled=""></option>
<option value="0">0</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
<option value="5">5</option>
</select> </div>
<div class="clear"></div>
<div class="c1">Play <span style="color:red;">*</span><br>e.g. not engaging in pretend/imaginative play at an age appropriate level, shows only repetitive/copied play, limited interests, not able to join in with shared play activities</div>
<div class="c2"><select name="skills_play" required="">
<option value="" selected="selected" disabled=""></option>
<option value="0">0</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
<option value="5">5</option>
</select> </div>
<div class="clear"></div>
<div class="c1">Voice <span style="color:red;">*</span><br>e.g. persistent hoarse/weak voice quality, vocal nodules, excessively nasal voice quality</div>
<div class="c2"><select name="skills_voice" required="">
<option value="" selected="selected" disabled=""></option>
<option value="0">0</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
<option value="5">5</option>
</select> </div>
<div class="clear"></div>
<div class="c1">Dysfluency <span style="color:red;">*</span><br>e.g. Stammering/Stuttering, not being able to ‘get words out’ with ease </div>
<div class="c2"><select name="skills_dysfluency" required="">
<option value="" selected="selected" disabled=""></option>
<option value="0">0</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
<option value="5">5</option>
</select> </div>
<div class="clear"></div>
<div class="c1">Do you have any other areas of concern?</div>
<div class="c2"><input type="text" name="other_concern_details" value=""></div>
<div class="clear"></div>
<div class="c1">Describe why these are areas of concern for you</div>
<div class="c2"><input type="text" name="concern_details" value=""></div>
<div class="clear"></div>
</div>
<div class="inputbox">
<div class="c100">What interventions/support have been or are currently in place for the child/young person</div>
<div class="clear"></div>
<br>
<div class="c1">Details <span style="color:red;">*</span></div>
<div class="c2"><textarea rows="6" name="interventions_details" required=""></textarea></div>
<div class="clear"></div>
</div>
<h4>WellComm assessment (if available) </h4>
<div class="inputbox">
<div class="c1">Please advise if you can provide either an Early Years or Primary WellComm Score, or neither<br><br>NB. If you confirm any WellComm assessment is available, please be advised we expect to see all scores and details of which
questions the child/young person got wrong, from and including their age appropriate section back to the section that the WellComm score shows green. If you cannot supply this detail in full, please advise ‘Unable to complete a WellComm
score’ and the Communicate SLT CIC team will contact you in due course to assist with this<span style="color:red;">*</span></div>
<div class="c2"><select name="welcomtype" class="welcomtype" onchange="wellcom();" required="">
<option value="" selected="selected" disabled=""></option>
<option value="Early Years">Early Years</option>
<option value="Primary">Primary </option>
<option value="Unable to complete a WellComm score">Unable to complete a WellComm score - Communicate SLT CIC will contact you to support achievement of this</option>
</select> </div>
<div class="clear"></div>
</div>
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}
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<script>
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early_years2 = $('.primary_y option:selected').val();
early_months = $('.primary_m option:selected').val();
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var early_years = parseFloat(early_years2).toFixed(0) * 12;
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var early_years = 0;
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var total_months = parseInt(early_years) + parseInt(early_months);
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<div class="hidewelcom1" style="display:none;">
<div class="inputbox">
<div class="c100"><strong>Early Years WellComm Scores</strong></div>
<div class="clear"></div>
<br>
<div class="c1">Date assessment was completed</div>
<div class="c2"><input type="text" class="datepicker early_date hasDatepicker" name="early_date" value="" readonly="" id="dp1720015042947"></div>
<div class="clear"></div>
<div class="c1">Age of the child/young person at the point of testing</div>
<div class="c2">
<select name="early_y" class="early_y" style="width:50px;" onchange="runtype('early');">
<option value=""></option>
<option value="0" selected="selected">0</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
<option value="5">5</option>
</select> years <select name="early_m" class="early_m" style="width:50px;" onchange="runtype('early');">
<option value=""></option>
<option value="0" selected="selected">0</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
<option value="5">5</option>
<option value="6">6</option>
<option value="7">7</option>
<option value="8">8</option>
<option value="9">9</option>
<option value="10">10</option>
<option value="11">11</option>
</select> months
</div>
<div class="clear"></div>
<div class="c1">Who the test was assessed by (name and role if possible) </div>
<div class="c2"><input type="text" name="early_assessed" class="early_assessed" value=""></div>
<div class="clear"></div>
</div>
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if ($('.early_1_score').val() >= 8) {
$('.early_1_score_rag').css("background-color", "green");
} else if ($('.early_1_score').val() >= 6) {
$('.early_1_score_rag').css("background-color", "#FFBF00");
} else if ($('.early_1_score').val() >= 0) {
$('.early_1_score_rag').css("background-color", "red");
}
}
}
if (type == "early" && id == 2) {
if ($('.early_2_score').val()) {
if ($('.early_2_score').val() >= 7) {
$('.early_2_score_rag').css("background-color", "green");
} else if ($('.early_2_score').val() >= 5) {
$('.early_2_score_rag').css("background-color", "#FFBF00");
$('.early_1_score').prop('required', true);
$('.early_1_questions').prop('required', true);
} else if ($('.early_2_score').val() >= 0) {
$('.early_2_score_rag').css("background-color", "red");
$('.early_1_score').prop('required', true);
$('.early_1_questions').prop('required', true);
}
}
}
if (type == "early" && id == 3) {
if ($('.early_3_score').val()) {
if ($('.early_3_score').val() >= 8) {
$('.early_3_score_rag').css("background-color", "green");
} else if ($('.early_3_score').val() >= 6) {
$('.early_3_score_rag').css("background-color", "#FFBF00");
$('.early_2_score').prop('required', true);
$('.early_2_questions').prop('required', true);
} else if ($('.early_3_score').val() >= 0) {
$('.early_3_score_rag').css("background-color", "red");
$('.early_2_score').prop('required', true);
$('.early_2_questions').prop('required', true);
}
}
}
if (type == "early" && id == 4) {
if ($('.early_4_score').val()) {
if ($('.early_4_score').val() >= 7) {
$('.early_4_score_rag').css("background-color", "green");
} else if ($('.early_4_score').val() >= 5) {
$('.early_4_score_rag').css("background-color", "#FFBF00");
$('.early_3_score').prop('required', true);
$('.early_3_questions').prop('required', true);
} else if ($('.early_4_score').val() >= 0) {
$('.early_4_score_rag').css("background-color", "red");
$('.early_3_score').prop('required', true);
$('.early_3_questions').prop('required', true);
}
}
}
if (type == "early" && id == 5) {
if ($('.early_5_score').val()) {
if ($('.early_5_score').val() >= 6) {
$('.early_5_score_rag').css("background-color", "green");
} else if ($('.early_5_score').val() >= 6) {
$('.early_5_score_rag').css("background-color", "#FFBF00");
$('.early_4_score').prop('required', true);
$('.early_4_questions').prop('required', true);
} else if ($('.early_5_score').val() >= 0) {
$('.early_5_score_rag').css("background-color", "red");
$('.early_4_score').prop('required', true);
$('.early_4_questions').prop('required', true);
}
}
}
if (type == "early" && id == 6) {
if ($('.early_6_score').val()) {
if ($('.early_6_score').val() >= 7) {
$('.early_6_score_rag').css("background-color", "green");
} else if ($('.early_6_score').val() >= 4) {
$('.early_6_score_rag').css("background-color", "#FFBF00");
$('.early_5_score').prop('required', true);
$('.early_5_questions').prop('required', true);
} else if ($('.early_6_score').val() >= 0) {
$('.early_6_score_rag').css("background-color", "red");
$('.early_5_score').prop('required', true);
$('.early_5_questions').prop('required', true);
}
}
}
if (type == "early" && id == 7) {
if ($('.early_7_score').val()) {
if ($('.early_7_score').val() >= 6) {
$('.early_7_score_rag').css("background-color", "green");
} else if ($('.early_7_score').val() >= 4) {
$('.early_7_score_rag').css("background-color", "#FFBF00");
$('.early_6_score').prop('required', true);
$('.early_6_questions').prop('required', true);
} else if ($('.early_7_score').val() >= 0) {
$('.early_7_score_rag').css("background-color", "red");
$('.early_6_score').prop('required', true);
$('.early_6_questions').prop('required', true);
}
}
}
if (type == "early" && id == 8) {
if ($('.early_8_score').val()) {
if ($('.early_8_score').val() >= 8) {
$('.early_8_score_rag').css("background-color", "green");
} else if ($('.early_8_score').val() >= 6) {
$('.early_8_score_rag').css("background-color", "#FFBF00");
$('.early_7_score').prop('required', true);
$('.early_7_questions').prop('required', true);
} else if ($('.early_8_score').val() >= 0) {
$('.early_8_score_rag').css("background-color", "red");
$('.early_7_score').prop('required', true);
$('.early_7_questions').prop('required', true);
}
}
}
if (type == "early" && id == 9) {
if ($('.early_9_score').val()) {
if ($('.early_9_score').val() >= 7) {
$('.early_9_score_rag').css("background-color", "green");
} else if ($('.early_9_score').val() >= 4) {
$('.early_9_score_rag').css("background-color", "#FFBF00");
$('.early_8_score').prop('required', true);
$('.early_8_questions').prop('required', true);
} else if ($('.early_9_score').val() >= 0) {
$('.early_9_score_rag').css("background-color", "red");
$('.early_8_score').prop('required', true);
$('.early_8_questions').prop('required', true);
}
}
}
if (type == "primary" && id == 1) {
if ($('.primary_1_score').val()) {
if ($('.primary_1_score').val() >= 7) {
$('.primary_1_score_rag').css("background-color", "green");
} else if ($('.primary_1_score').val() >= 6) {
$('.primary_1_score_rag').css("background-color", "#FFBF00");
} else if ($('.primary_1_score').val() >= 0) {
$('.primary_1_score_rag').css("background-color", "red");
}
}
}
if (type == "primary" && id == 2) {
if ($('.primary_2_score').val()) {
if ($('.primary_2_score').val() >= 8) {
$('.primary_2_score_rag').css("background-color", "green");
} else if ($('.primary_2_score').val() >= 6) {
$('.primary_2_score_rag').css("background-color", "#FFBF00");
$('.primary_1_score').prop('required', true);
$('.primary_1_questions').prop('required', true);
} else if ($('.primary_2_score').val() >= 0) {
$('.primary_2_score_rag').css("background-color", "red");
$('.primary_1_score').prop('required', true);
$('.primary_1_questions').prop('required', true);
}
}
}
if (type == "primary" && id == 3) {
if ($('.primary_3_score').val()) {
if ($('.primary_3_score').val() >= 8) {
$('.primary_3_score_rag').css("background-color", "green");
} else if ($('.primary_3_score').val() >= 7) {
$('.primary_3_score_rag').css("background-color", "#FFBF00");
$('.primary_2_score').prop('required', true);
$('.primary_2_questions').prop('required', true);
} else if ($('.primary_3_score').val() >= 0) {
$('.primary_3_score_rag').css("background-color", "red");
$('.primary_2_score').prop('required', true);
$('.primary_2_questions').prop('required', true);
}
}
}
if (type == "primary" && id == 4) {
if ($('.primary_4_score').val()) {
if ($('.primary_4_score').val() >= 8) {
$('.primary_4_score_rag').css("background-color", "green");
} else if ($('.primary_4_score').val() >= 7) {
$('.primary_4_score_rag').css("background-color", "#FFBF00");
$('.primary_3_score').prop('required', true);
$('.primary_3_questions').prop('required', true);
} else if ($('.primary_4_score').val() >= 0) {
$('.primary_4_score_rag').css("background-color", "red");
$('.primary_3_score').prop('required', true);
$('.primary_3_questions').prop('required', true);
}
}
}
}
</script>
<div class="inputbox">
<div class="c20"><strong>Section</strong></div>
<div class="c20"><strong>Age Related Section</strong></div>
<div class="c20"><strong>Score /10</strong></div>
<div class="c20"><strong>RAG</strong></div>
<div class="c20"><strong>Which question numbers did the child/young person get wrong?</strong></div>
<div class="clear"></div>
<div class="c20">1</div>
<div class="c20">6-11 mths</div>
<div class="c20"><select name="early_1_score" class="early_1_score" onchange="checkrag('early','1');">
<option value=""></option>
<option value="0" selected="selected">0</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
<option value="5">5</option>
<option value="6">6</option>
<option value="7">7</option>
<option value="8">8</option>
<option value="9">9</option>
<option value="10">10</option>
</select></div>
<div class="c20">
<div class="early_1_score_rag"> </div>
</div>
<div class="c20"><input type="text" name="early_1_questions" class="early_1_questions" value=""></div>
<div class="clear"></div>
<div class="c20">2</div>
<div class="c20">1.0-1.5 yrs</div>
<div class="c20"><select name="early_2_score" class="early_2_score" onchange="checkrag('early','2');">
<option value=""></option>
<option value="0" selected="selected">0</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
<option value="5">5</option>
<option value="6">6</option>
<option value="7">7</option>
<option value="8">8</option>
<option value="9">9</option>
<option value="10">10</option>
</select></div>
<div class="c20">
<div class="early_2_score_rag"> </div>
</div>
<div class="c20"><input type="text" name="early_2_questions" class="early_2_questions" value=""></div>
<div class="clear"></div>
<div class="c20">3</div>
<div class="c20">1.6-1.11 yrs</div>
<div class="c20"><select name="early_3_score" class="early_3_score" onchange="checkrag('early','3');">
<option value=""></option>
<option value="0" selected="selected">0</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
<option value="5">5</option>
<option value="6">6</option>
<option value="7">7</option>
<option value="8">8</option>
<option value="9">9</option>
<option value="10">10</option>
</select></div>
<div class="c20">
<div class="early_3_score_rag"> </div>
</div>
<div class="c20"><input type="text" name="early_3_questions" class="early_3_questions" value=""></div>
<div class="clear"></div>
<div class="c20">4</div>
<div class="c20">2.0-2.5 yrs</div>
<div class="c20"><select name="early_4_score" class="early_4_score" onchange="checkrag('early','4');">
<option value=""></option>
<option value="0" selected="selected">0</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
<option value="5">5</option>
<option value="6">6</option>
<option value="7">7</option>
<option value="8">8</option>
<option value="9">9</option>
<option value="10">10</option>
</select></div>
<div class="c20">
<div class="early_4_score_rag"> </div>
</div>
<div class="c20"><input type="text" name="early_4_questions" class="early_4_questions" value=""></div>
<div class="clear"></div>
<div class="c20">5</div>
<div class="c20">2.6-2.11 yrs</div>
<div class="c20"><select name="early_5_score" class="early_5_score" onchange="checkrag('early','5');">
<option value=""></option>
<option value="0" selected="selected">0</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
<option value="5">5</option>
<option value="6">6</option>
<option value="7">7</option>
<option value="8">8</option>
<option value="9">9</option>
<option value="10">10</option>
</select></div>
<div class="c20">
<div class="early_5_score_rag"> </div>
</div>
<div class="c20"><input type="text" name="early_5_questions" class="early_5_questions" value=""></div>
<div class="clear"></div>
<div class="c20">6</div>
<div class="c20">3.0-3.5 yrs</div>
<div class="c20"><select name="early_6_score" class="early_6_score" onchange="checkrag('early','6');">
<option value=""></option>
<option value="0" selected="selected">0</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
<option value="5">5</option>
<option value="6">6</option>
<option value="7">7</option>
<option value="8">8</option>
<option value="9">9</option>
<option value="10">10</option>
</select></div>
<div class="c20">
<div class="early_6_score_rag"> </div>
</div>
<div class="c20"><input type="text" name="early_6_questions" class="early_6_questions" value=""></div>
<div class="clear"></div>
<div class="c20">7</div>
<div class="c20">3.6-3.11 yrs</div>
<div class="c20"><select name="early_7_score" class="early_7_score" onchange="checkrag('early','7');">
<option value=""></option>
<option value="0" selected="selected">0</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
<option value="5">5</option>
<option value="6">6</option>
<option value="7">7</option>
<option value="8">8</option>
<option value="9">9</option>
<option value="10">10</option>
</select></div>
<div class="c20">
<div class="early_7_score_rag"> </div>
</div>
<div class="c20"><input type="text" name="early_7_questions" class="early_7_questions" value=""></div>
<div class="clear"></div>
<div class="c20">8</div>
<div class="c20">4.0-4.11 yrs</div>
<div class="c20"><select name="early_8_score" class="early_8_score" onchange="checkrag('early','8');">
<option value=""></option>
<option value="0" selected="selected">0</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
<option value="5">5</option>
<option value="6">6</option>
<option value="7">7</option>
<option value="8">8</option>
<option value="9">9</option>
<option value="10">10</option>
</select></div>
<div class="c20">
<div class="early_8_score_rag"> </div>
</div>
<div class="c20"><input type="text" name="early_8_questions" class="early_8_questions" value=""></div>
<div class="clear"></div>
<div class="c20">9</div>
<div class="c20">5.0-5.11 yrs</div>
<div class="c20"><select name="early_9_score" class="early_9_score" onchange="checkrag('early','9');">
<option value=""></option>
<option value="0" selected="selected">0</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
<option value="5">5</option>
<option value="6">6</option>
<option value="7">7</option>
<option value="8">8</option>
<option value="9">9</option>
<option value="10">10</option>
</select></div>
<div class="c20">
<div class="early_9_score_rag"> </div>
</div>
<div class="c20"><input type="text" name="early_9_questions" class="early_9_questions" value=""></div>
<div class="clear"></div>
</div>
</div>
<div class="hidewelcom2" style="display:none;">
<div class="inputbox">
<div class="c100"><strong>Primary WellComm Scores</strong></div>
<div class="clear"></div>
<br>
<div class="c1">Date assessment was completed</div>
<div class="c2"><input type="text" class="datepicker primary_date hasDatepicker" name="primary_date" value="" readonly="" id="dp1720015042948"></div>
<div class="clear"></div>
<div class="c1">Age of the child/young person at the point of testing </div>
<div class="c2">
<select name="primary_y" class="primary_y" style="width:50px;" onchange="runtype('primary');">
<option value=""></option>
<option value="6">6</option>
<option value="7">7</option>
<option value="8">8</option>
<option value="9">9</option>
</select> years <select name="primary_m" class="primary_m" style="width:50px;" onchange="runtype('primary');">
<option value=""></option>
<option value="0" selected="selected">0</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
<option value="5">5</option>
<option value="6">6</option>
<option value="7">7</option>
<option value="8">8</option>
<option value="9">9</option>
<option value="10">10</option>
<option value="11">11</option>
</select> months
</div>
<div class="clear"></div>
<div class="c1">Who the test was assessed by (name and role if possible) </div>
<div class="c2"><input type="text" name="primary_assessed" class="primary_assessed" value=""></div>
<div class="clear"></div>
</div>
<div class="inputbox">
<div class="c20"><strong>Section</strong></div>
<div class="c20"><strong>Age Related Section</strong></div>
<div class="c20"><strong>Score</strong></div>
<div class="c20"><strong>RAG</strong></div>
<div class="c20"><strong>Which question numbers did the child/young person get wrong?</strong></div>
<div class="clear"></div>
<div class="c20">1</div>
<div class="c20">6.0-6.11 yrs</div>
<div class="c20"><select name="primary_1_score" class="primary_1_score" onchange="checkrag('primary','1');">
<option value=""></option>
<option value="0" selected="selected">0</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
<option value="5">5</option>
<option value="6">6</option>
<option value="7">7</option>
<option value="8">8</option>
<option value="9">9</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
</select></div>
<div class="c20">
<div class="primary_1_score_rag"> </div>
</div>
<div class="c20"><input type="text" name="primary_1_questions" class="primary_1_questions" value=""></div>
<div class="clear"></div>
<div class="c20">2</div>
<div class="c20">7.0-7.11 yrs</div>
<div class="c20"><select name="primary_2_score" class="primary_2_score" onchange="checkrag('primary','2');">
<option value=""></option>
<option value="0" selected="selected">0</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
<option value="5">5</option>
<option value="6">6</option>
<option value="7">7</option>
<option value="8">8</option>
<option value="9">9</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
</select></div>
<div class="c20">
<div class="primary_2_score_rag"> </div>
</div>
<div class="c20"><input type="text" name="primary_2_questions" class="primary_2_questions" value=""></div>
<div class="clear"></div>
<div class="c20">3</div>
<div class="c20">8.0-8.11 yrs</div>
<div class="c20"><select name="primary_3_score" class="primary_3_score" onchange="checkrag('primary','3');">
<option value=""></option>
<option value="0" selected="selected">0</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
<option value="5">5</option>
<option value="6">6</option>
<option value="7">7</option>
<option value="8">8</option>
<option value="9">9</option>
<option value="10">10</option>
</select></div>
<div class="c20">
<div class="primary_3_score_rag"> </div>
</div>
<div class="c20"><input type="text" name="primary_3_questions" class="primary_3_questions" value=""></div>
<div class="clear"></div>
<div class="c20">4</div>
<div class="c20">9.0-9.11 yrs</div>
<div class="c20"><select name="primary_4_score" class="primary_4_score" onchange="checkrag('primary','4');">
<option value=""></option>
<option value="0" selected="selected">0</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
<option value="5">5</option>
<option value="6">6</option>
<option value="7">7</option>
<option value="8">8</option>
<option value="9">9</option>
<option value="10">10</option>
<option value="11">11</option>
</select></div>
<div class="c20">
<div class="primary_4_score_rag"> </div>
</div>
<div class="c20"><input type="text" name="primary_4_questions" class="primary_4_questions" value=""></div>
<div class="clear"></div>
</div>
</div>
<h4>Supporting Documentation</h4>
<p>Please attach any relevant documentation Communicate SLT CIC might find useful to support to this referral. <span style="color:red;">If possible, please ensure each document has in its title the referred child/young person’s <strong>initials
and date of birth only</strong>. Thank you.</span></p>
<div class="inputbox">
<div class="c1">Attachment 1</div>
<div class="c2"><input type="file" name="file_consent"></div>
<div class="clear"></div>
<div class="c1">Attachment 2</div>
<div class="c2"><input type="file" name="file_education"></div>
<div class="clear"></div>
<div class="c1">Attachment 3</div>
<div class="c2"><input type="file" name="file_agencies"></div>
<div class="clear"></div>
<div class="c1">Attachment 4</div>
<div class="c2"><input type="file" name="file_ehcp"></div>
<div class="clear"></div>
</div>
<p><input type="submit" class="mainsubmitbutton" name="a" value="Submit"></p>
</div>
</form>Text Content
COMMUNICATE SLT COMMUNITY INTEREST COMPANY (CIC) REQUEST FOR PAEDIATRIC SPEECH AND LANGUAGE THERAPY (SLT) SERVICES REFERRER (THE REFERRER IS THE PERSON COMPLETING THIS FORM) PLEASE READ BEFORE COMPLETING THIS FORM. It is assumed that the person completing this form either is the parent or carer or the person with parental responsibility for the referred child/young person. If you are not, please ensure that you have sought consent to complete this document on behalf of the person who has parental responsibility. Please also ensure the section below has your personal details in it – please do not complete the Referrer section with details which are for a company, professional body or the name of the child/young person as this will invalidate the request for services. Referrer Forename * Referrer Family name * Referrer Role or relationship with the child/young person * Mother Father Grandparent Foster Parent Legal Guardian Other Other (please specify) Referrer Contact email * Referrer Contact telephone number * -------------------------------------------------------------------------------- Find address Find Address -------------------------------------------------------------------------------- Referrer Address * Referrer Town * Referrer County * Referrer Country * United KingdomAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua And BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia And HerzegowinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo, The Democratic Republic Of TheCook IslandsCosta RicaCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard And Mc Donald IslandsHoly See (Vatican City State)HondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic Of)IraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLatviaLebanonLesothoLiberiaLibyan Arab JamahiriyaLiechtensteinLithuaniaLuxembourgMacauMacedonia, Former Yugoslav Republic OfMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia, Federated States OfMoldova, Republic OfMonacoMongoliaMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussian FederationRwandaSaint Kitts And NevisSaint LuciaSaint Vincent And The GrenadinesSamoaSan MarinoSao Tome And PrincipeSaudi ArabiaSenegalSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia, South Sandwich IslandsSouth KoreaSpainSri LankaSt. HelenaSt. Pierre And MiquelonSudanSurinameSvalbard And Jan Mayen IslandsSwazilandSwedenSwitzerlandSyrian Arab RepublicTaiwanTajikistanTanzania, United Republic OfThailandTogoTokelauTongaTrinidad And TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands (British)Virgin Islands (U.S.)Wallis And Futuna IslandsWestern SaharaYemenYugoslaviaZambiaZimbabwe Referrer Postcode * CONSENT Please remember that you must either be the parent or carer or the person with parental responsibility for the referred child/young person to answer these. If you are not, please ensure that you have sought consent to complete this document on behalf of the person who has parental responsibility before you proceed. From now on, we will use the term referrer assuming you are one of the above named individuals or someone who has consent to refer. I the referrer, confirm that I either have parental responsibility for or permission from the person/people who do, to complete this Request for Paediatric Speech and Language Therapy (SLT) Services form?* No Yes We cannot continue with this referral without consent from the relevant individual. Please can we advise that you seek this consent and begin the referral online once again. Thank you, from the Communicate SLT CIC team I the referrer, confirm that I either have parental responsibility for or permission from the person/people who do, and that relevant details can be shared by Communicate SLT CIC with other professions involved in the referred child/young person’s care/education? No Yes This question is only for those who are making a request for services for a child/young person who was, at 30 October 2023, on Chatterbug Ltd’s caseload. If you were not, please answer N/A. I the referrer, confirm that I either have parental responsibility for or permission from the person/people who do and, if it is required to do so, Communicate SLT have their permission to provide the SLT services their child/young person requires and to add any data Chatterbug has supplied to a patient record which we will hold? No Yes N/A Do Communicate SLT CIC have your permission to contact you in the future with relevant information? No Yes CHILD/YOUNG PERSON'S DETAILS Child/young person's forename* Child/young person's family name * Child/young person's date of birth (DOB) * Child/young person's gender at birth * Male Female Child/young person's gender identity Child/young person's ethnicity Prefer not to say Asian or Asian British - Indian Asian or Asian British - Pakistani Asian or Asian British - Bangladeshi Asian or Asian British - Chinese Asian or Asian British - Any Other Asian Background Black, Black British, Caribbean or African - Caribbean Black, Black British, Caribbean or African - African Black, Black British, Caribbean or African - Any Other Black, Black British or Caribbean Background Mixed or Multiple Ethnic Groups - White and Black Caribbean Mixed or Multiple Ethnic Groups - White and Black African Mixed or Multiple Ethnic Groups - White and Asian Mixed or Multiple Ethnic Groups - Any Other Mixed or Multiple Ethnic Background White - English, Welsh, Scottish, Northern Irish or British White - Irish White - Gypsy or Irish Traveller White - Roma White - Any Other White Background Other Ethnic Group - Arab Other Ethnic Group - Any Other Ethnic Group Does the child/young person have an Education, Health and Care Plan (EHCP) in place? * Yes No PARENT/CARER 1 (MAIN PARENT/CARER) Parent/carer 1's forename * Parent/carer 1's family name * Parent/carer 1's relationship to the child/young person * Mother Father Grandparent Foster Parent Legal Guardian Other Does this person have parental responsibility for the referred child/young person * Yes No Find address Find Address -------------------------------------------------------------------------------- Parent/carer 1's home address * Parent/carer 1's town * Parent/carer 1's county * Parent/carer 1's country * United KingdomAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua And BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia And HerzegowinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo, The Democratic Republic Of TheCook IslandsCosta RicaCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard And Mc Donald IslandsHoly See (Vatican City State)HondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic Of)IraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLatviaLebanonLesothoLiberiaLibyan Arab JamahiriyaLiechtensteinLithuaniaLuxembourgMacauMacedonia, Former Yugoslav Republic OfMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia, Federated States OfMoldova, Republic OfMonacoMongoliaMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussian FederationRwandaSaint Kitts And NevisSaint LuciaSaint Vincent And The GrenadinesSamoaSan MarinoSao Tome And PrincipeSaudi ArabiaSenegalSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia, South Sandwich IslandsSouth KoreaSpainSri LankaSt. HelenaSt. Pierre And MiquelonSudanSurinameSvalbard And Jan Mayen IslandsSwazilandSwedenSwitzerlandSyrian Arab RepublicTaiwanTajikistanTanzania, United Republic OfThailandTogoTokelauTongaTrinidad And TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands (British)Virgin Islands (U.S.)Wallis And Futuna IslandsWestern SaharaYemenYugoslaviaZambiaZimbabwe Parent/carer 1's postcode * Parent/carer 1's telephone number * Parent/carer 1's email address * PARENT/CARER 2 (OPTIONAL) Parent/carer 2's forename Parent/carer 2's family name Parent/carer 2's relationship to the child/young person Mother Father Grandparent Foster Parent Legal Guardian Other Does this person have parental responsibility for the referred child/young person Yes No Find address Find Address -------------------------------------------------------------------------------- Parent/carer 2's home address Parent/carer 2's town Parent/carer 2's county Parent/carer 2's country United KingdomAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua And BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia And HerzegowinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo, The Democratic Republic Of TheCook IslandsCosta RicaCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard And Mc Donald IslandsHoly See (Vatican City State)HondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic Of)IraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLatviaLebanonLesothoLiberiaLibyan Arab JamahiriyaLiechtensteinLithuaniaLuxembourgMacauMacedonia, Former Yugoslav Republic OfMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia, Federated States OfMoldova, Republic OfMonacoMongoliaMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussian FederationRwandaSaint Kitts And NevisSaint LuciaSaint Vincent And The GrenadinesSamoaSan MarinoSao Tome And PrincipeSaudi ArabiaSenegalSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia, South Sandwich IslandsSouth KoreaSpainSri LankaSt. HelenaSt. Pierre And MiquelonSudanSurinameSvalbard And Jan Mayen IslandsSwazilandSwedenSwitzerlandSyrian Arab RepublicTaiwanTajikistanTanzania, United Republic OfThailandTogoTokelauTongaTrinidad And TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands (British)Virgin Islands (U.S.)Wallis And Futuna IslandsWestern SaharaYemenYugoslaviaZambiaZimbabwe Parent/carer 2's postcode Parent/carer 2's telephone number Parent/carer 2's email address As you have indicated that neither party listed above have parental responsibility, please let us know here who does and their contact details/relationship to the referred child/young person? CHILD/YOUNG PERSON'S ADDRESS (IF DIFFERENT TO THE ABOVE) Which of the above addresses does the child reside at? Parent/carer 1 Parent/carer 2 Neither Find address Find Address -------------------------------------------------------------------------------- Child/young person's address * Child/young person's town * Child/young person's county * Child/young person's country * United KingdomAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua And BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia And HerzegowinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo, The Democratic Republic Of TheCook IslandsCosta RicaCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard And Mc Donald IslandsHoly See (Vatican City State)HondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic Of)IraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLatviaLebanonLesothoLiberiaLibyan Arab JamahiriyaLiechtensteinLithuaniaLuxembourgMacauMacedonia, Former Yugoslav Republic OfMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia, Federated States OfMoldova, Republic OfMonacoMongoliaMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussian FederationRwandaSaint Kitts And NevisSaint LuciaSaint Vincent And The GrenadinesSamoaSan MarinoSao Tome And PrincipeSaudi ArabiaSenegalSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia, South Sandwich IslandsSouth KoreaSpainSri LankaSt. HelenaSt. Pierre And MiquelonSudanSurinameSvalbard And Jan Mayen IslandsSwazilandSwedenSwitzerlandSyrian Arab RepublicTaiwanTajikistanTanzania, United Republic OfThailandTogoTokelauTongaTrinidad And TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands (British)Virgin Islands (U.S.)Wallis And Futuna IslandsWestern SaharaYemenYugoslaviaZambiaZimbabwe Child/young person's postcode * SUPPORT WITH APPOINTMENTS If your child/young person has a preferred name, please detail this here. * Please be advised that all patient records and correspondence will – unless a legal change of name has occurred at which point we require paperwork to change this formally – will be in their legal name. We will do our best to refer to your child/young person informally by their preferred name. Is an interpreter needed to converse with parent/carer 1 or the person who has parental responsibility * No Yes If yes, what language should the interpreter speak Is an interpreter needed to converse with the child/young person? * No Yes If yes, what language should the interpreter speak Could the parent/carer or the person who has parental responsibility struggle to read and understand appointment letters written in English? Please be advised if you answer ‘Yes’ to this question, Communicate SLT will assume you have consent from them for us to send copies of appointment letters to a professional named by the you, to support interaction with us * No Yes – I will share details of the named professional when prompted below Not Applicable If yes, do you as the referrer confirm the parent/carer consents for copies of appointment letters to be shared with a professional to support attendance? Please provide this professional's name here and ensure that their full contact details are entered below in the Agencies Involved section. EDUCATIONAL SETTING DETAILS Educational setting type * School Nursery Childminder Home Educated Do not attend an educational setting – if you choose this option, we do not expect to see an address listed below Educational setting name * (If you have answered 'Does not attend an educational setting' in the question above, please share more details here if you can) -------------------------------------------------------------------------------- Find address Find Address -------------------------------------------------------------------------------- Educational setting address Educational setting town Educational setting county Educational setting country United KingdomAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua And BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia And HerzegowinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo, The Democratic Republic Of TheCook IslandsCosta RicaCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard And Mc Donald IslandsHoly See (Vatican City State)HondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic Of)IraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLatviaLebanonLesothoLiberiaLibyan Arab JamahiriyaLiechtensteinLithuaniaLuxembourgMacauMacedonia, Former Yugoslav Republic OfMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia, Federated States OfMoldova, Republic OfMonacoMongoliaMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussian FederationRwandaSaint Kitts And NevisSaint LuciaSaint Vincent And The GrenadinesSamoaSan MarinoSao Tome And PrincipeSaudi ArabiaSenegalSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia, South Sandwich IslandsSouth KoreaSpainSri LankaSt. HelenaSt. Pierre And MiquelonSudanSurinameSvalbard And Jan Mayen IslandsSwazilandSwedenSwitzerlandSyrian Arab RepublicTaiwanTajikistanTanzania, United Republic OfThailandTogoTokelauTongaTrinidad And TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands (British)Virgin Islands (U.S.)Wallis And Futuna IslandsWestern SaharaYemenYugoslaviaZambiaZimbabwe Educational setting postcode Person to contact at educational setting Educational setting email address (if known) Educational setting telephone number (if known) Year group/class (please enter N/A if this does not apply) * What times and days of the week does the referred child/young person usually attend their educational setting? Tick all that apply Day AM PM Monday Tuesday Wednesday Thursday Friday Does the referred child/young person attend the educational setting term time only or all year round? * Term Time Only All Year Round EXISTING FAMILY SUPPORT Is there a Multi-Agency Plan (MAP), Early Help Assessment (EHA) or Early Help Plan (EHP) in place? * Yes No Is there a child/young person protection plan in place? * Yes No Is there a child/young person in need plan in place? * Yes No Is the child/young person in the care of the Local Authority? * Yes No EXISTING DIAGNOSES DOES THE CHILD/YOUNG PERSON HAVE A CURRENT DIAGNOSIS OF ANY OF THE FOLLOWING Please share details of anything else you feel might be relevant from the child/young person’s medical history and let us know what medication and/or physical and/or mental health support is already in place. You may wish to share with us information around vision tests, hearing tests, allergies, physical needs for example. ADHD * No Yes Don't Know Autism * No Yes Don't Know Cerebral Palsy * No Yes Don't Know Cleft Lip and Palate * No Yes Don't Know Hearing Impairment * No Yes Don't Know Learning Disability * No Yes Don't Know Selective Mutism * No Yes Don't Know Social, Emotional and Mental Health Needs (SEMH Needs) * No Yes Don't Know Other Please share any other relevant medical history and support/medication in place (e.g. recent hearing, vision test, allergies, epilepsy, mental health, physical needs, other) Details EXISTING AGENCIES INVOLVED GP practice name -------------------------------------------------------------------------------- Find address Find Address -------------------------------------------------------------------------------- GP address * GP town * GP county * GP country * United KingdomAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua And BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia And HerzegowinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo, The Democratic Republic Of TheCook IslandsCosta RicaCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard And Mc Donald IslandsHoly See (Vatican City State)HondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic Of)IraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLatviaLebanonLesothoLiberiaLibyan Arab JamahiriyaLiechtensteinLithuaniaLuxembourgMacauMacedonia, Former Yugoslav Republic OfMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia, Federated States OfMoldova, Republic OfMonacoMongoliaMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussian FederationRwandaSaint Kitts And NevisSaint LuciaSaint Vincent And The GrenadinesSamoaSan MarinoSao Tome And PrincipeSaudi ArabiaSenegalSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia, South Sandwich IslandsSouth KoreaSpainSri LankaSt. HelenaSt. Pierre And MiquelonSudanSurinameSvalbard And Jan Mayen IslandsSwazilandSwedenSwitzerlandSyrian Arab RepublicTaiwanTajikistanTanzania, United Republic OfThailandTogoTokelauTongaTrinidad And TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands (British)Virgin Islands (U.S.)Wallis And Futuna IslandsWestern SaharaYemenYugoslaviaZambiaZimbabwe GP postcode * Speech and Language Therapy * No Yes If yes, please provide the Therapist's name and contact details Occupational Therapy * No Yes If yes, please provide the Therapist's name and contact details * Physiotherapy * No Yes If yes, please provide the Therapist's name and contact details Paediatrician * No Yes If yes, please provide the Paediatrician's name and contact details Social Services * No Yes If yes, please provide the name of your contact at Social Services and their contact details Advisory Teachers * No Yes If yes, please provide the Teacher's name and contact details Education Psychology * No Yes If yes, please provide the Psychologist's name and contact details CAMHS * No Yes If yes, please provide details of the CAMHS service supporting the child/young person Has the Special Educational Needs Co-Ordinator (SENCo) in an educational setting been informed of this referral? * No Yes Other – please give as much detail as possible, including the name, profession and postal address of the professional to whom you require Communicate SLT to send copies of appointments to, should you have indicated a language barrier earlier in this referral. Has this child/young person been referred to speech and language therapy services previously? * No Yes Don't Know If you have answered yes or don’t know, please provide as much detail as you can here. You may be able to advise who the therapy provider was, when the therapy took place, what practices you were asked to put in place for example. AREAS OF CONCERN What is your main area of concern? (Score 0 for no concerns at all and 5 for severe difficulties in this area) Attention and Listening * e.g. poor concentration, highly distractable, not able to focus on adult led activities for an age appropriate length of time 0 1 2 3 4 5 Understanding Language * e.g. not able to follow instructions, answer questions, or understand concepts at an age appropriate level 0 1 2 3 4 5 Expressive Language (talking) * e.g. limited vocabulary development, difficulties using age appropriate spoken grammar/sentence structure, word finding difficulties 0 1 2 3 4 5 Speech/Articulation * e.g. unclear speech, incorrect or limited speech sounds used 0 1 2 3 4 5 Social Skills * e.g. difficulties with turn taking, keeping to topic, literal interpretation of language, limited awareness of other children/adults, difficulties with friendships 0 1 2 3 4 5 Play * e.g. not engaging in pretend/imaginative play at an age appropriate level, shows only repetitive/copied play, limited interests, not able to join in with shared play activities 0 1 2 3 4 5 Voice * e.g. persistent hoarse/weak voice quality, vocal nodules, excessively nasal voice quality 0 1 2 3 4 5 Dysfluency * e.g. Stammering/Stuttering, not being able to ‘get words out’ with ease 0 1 2 3 4 5 Do you have any other areas of concern? Describe why these are areas of concern for you What interventions/support have been or are currently in place for the child/young person Details * WELLCOMM ASSESSMENT (IF AVAILABLE) Please advise if you can provide either an Early Years or Primary WellComm Score, or neither NB. If you confirm any WellComm assessment is available, please be advised we expect to see all scores and details of which questions the child/young person got wrong, from and including their age appropriate section back to the section that the WellComm score shows green. If you cannot supply this detail in full, please advise ‘Unable to complete a WellComm score’ and the Communicate SLT CIC team will contact you in due course to assist with this* Early Years Primary Unable to complete a WellComm score - Communicate SLT CIC will contact you to support achievement of this Early Years WellComm Scores Date assessment was completed Age of the child/young person at the point of testing 0 1 2 3 4 5 years 0 1 2 3 4 5 6 7 8 9 10 11 months Who the test was assessed by (name and role if possible) Section Age Related Section Score /10 RAG Which question numbers did the child/young person get wrong? 1 6-11 mths 0 1 2 3 4 5 6 7 8 9 10 2 1.0-1.5 yrs 0 1 2 3 4 5 6 7 8 9 10 3 1.6-1.11 yrs 0 1 2 3 4 5 6 7 8 9 10 4 2.0-2.5 yrs 0 1 2 3 4 5 6 7 8 9 10 5 2.6-2.11 yrs 0 1 2 3 4 5 6 7 8 9 10 6 3.0-3.5 yrs 0 1 2 3 4 5 6 7 8 9 10 7 3.6-3.11 yrs 0 1 2 3 4 5 6 7 8 9 10 8 4.0-4.11 yrs 0 1 2 3 4 5 6 7 8 9 10 9 5.0-5.11 yrs 0 1 2 3 4 5 6 7 8 9 10 Primary WellComm Scores Date assessment was completed Age of the child/young person at the point of testing 6 7 8 9 years 0 1 2 3 4 5 6 7 8 9 10 11 months Who the test was assessed by (name and role if possible) Section Age Related Section Score RAG Which question numbers did the child/young person get wrong? 1 6.0-6.11 yrs 0 1 2 3 4 5 6 7 8 9 10 11 12 2 7.0-7.11 yrs 0 1 2 3 4 5 6 7 8 9 10 11 12 3 8.0-8.11 yrs 0 1 2 3 4 5 6 7 8 9 10 4 9.0-9.11 yrs 0 1 2 3 4 5 6 7 8 9 10 11 SUPPORTING DOCUMENTATION Please attach any relevant documentation Communicate SLT CIC might find useful to support to this referral. If possible, please ensure each document has in its title the referred child/young person’s initials and date of birth only. Thank you. Attachment 1 Attachment 2 Attachment 3 Attachment 4