2 Roundway, Bramhall, Stockport. SK7 1DG
Tel: 0161 440 8685
This form prints on two pages

Please supply the following information (* indicates a required field)

Child's name*:  
Child's DOB*:  
Parent names*:  
Home address*:  
Home telephone*:  
Mobile:  
Email:  
GP's name:  
GP's address:  
School:  
What are your main concerns?  
Has the child already seen a speech and language therapist? YES\NO (please delete as appropriate)
Other professionals involved:  
Name of therapist seen:  
Address of therapist:  
 
Services we can offer
If you answer yes to one or more of the questions below then a speech and language therapist may be able to help
YES NO
Are you concerned about your child’s listening and concentration?    
Are you concerned about your child’s ability to relate to others or play with peers?    
Are you concerned about your child’s speech intelligibility?    
Are you concerned about your child’s ability to understand spoken language?    
Are you concerned about your child’s ability to speak in sentences?    
Do you have concerns about your child’s play?    
Do you have concerns about your child’s reading and writing?    
Are you concerned that your child’s not talking yet?    
Do you have difficulty understanding your child’s speech?    
Does your child have non-fluent speech which is beginning to cause concern?    
Does your child talk inappropriately about unrelated subjects?    
Do you find it difficult to have a conversation with your school-aged child?    
Does your child have difficulty making friendships?    
Does your child repeat your speech or phrases from videos and TV without understanding?    

 

Services we do not offer
We do not offer services for children with significant developmental problems other than communication problems. If you answer yes to one or more of the questions below, it is likely that your child may need to be seen by a different sort of professional.
YES NO
Are you concerned about your child’s general development?    
Do you have concerns about your child’s co-ordination?    
Does your child have difficulty with fine movements?    
Are you concerned about your child’s behaviour in general?    
Does your child have a hearing impairment?    
Does your child have a visual impairment?    
Do you have concerns about relationships with your child in general?