Speech and Language Therapy Referral Form Children with Dysphagia
Please complete this form if the child has difficulties with eating, drinking or swallowing.
This form is for children who require support to eat or drink safely.
Click here if you require support with your child’s speech, language or communication
We support children with:
- A genetic syndrome
- brain injury or cerebral palsy
- developmental delay
- heart defects
- cleft palate
We are unable to accept referrals for children with:
- Sensory difficulties (such as rejecting foods of certain colour, flavour or refusing to eat)
- Psychological eating and drinking difficulties (such as anxiety or phobia around eating or swallowing)
- Difficulties with weaning with no physical cause
- ARFID (Avoidant Restrictive Food Intake Disorder)
- Chronic cough when not eating and drinking
Without this form being fully completed we will not have the information we need to fully consider this referral and make a plan.
Please note: This referral form takes roughly 30 minutes to complete. You may need to gather additional information before you complete this form, e.g. digital copies of delegation of authority documents (if applicable), EHCP.
Please note: If this form is left unused for more than 120 seconds (2 minutes) it will timeout and you will need to restart. Please ensure you complete the form in one go.