Speech and Language Therapy Dysphagia Referral Form

WE ARE UNABLE TO ACCEPT INCOMPLETE FORMS (boxes with * are mandatory)

Note: To ensure a resident will be seen, an online referral form should be received 24 hours before the SLT visit is due.

I have completed the Referrals Flowchart* and the result indicates this referral is appropriate *

Consult the Referral Dysphagia Advice Leaflet ** 

To download/print a copy of this form, please click here.

Please select as appropriate:

Relevant Medical History

Please tick as appropriate:

Relevant Medication

Or causing the following:

Chest Infections

Current diet and fluids consistency


Clinical indicators that specialist swallowing assessment is required

Please select:

For residents declining swallowing recommendations

NB All health professionals are qualified/have a duty to assess capacity, it is not a specialist SLT skill

  • If the resident has capacity, it is their right to decline the recommendations. Document your capacity assessment and the resident’s decision clearly in the resident’s notes. There is no need to refer.
  • If the resident does not have capacity then the nursing home needs to make/facilitate a ‘best interest’ decision (involve the GP if necessary). Document this clearly in the resident’s notes. There is no need to refer.

A speech and language therapist should only be involved if the patient has a complex communication difficulty and specialist communication assessment is required to determine capacity.