Referral for Support | Portal: Aphasia Support

Please note: Our flexible programme of support currently includes:

One-to-one support in West Yorkshire (aged 18-64)
Group support across Yorkshire, Lancashire & Nottinghamshire
UK-wide access to our online Aphasia Cafe

Please select one of the following options:

I have aphasia

I am a carer or loved one

I am a Speech and Language Therapist

I am referring on behalf of an organisation (e.g. Stroke Association)

Please click link: I have aphasia

Please click link: I am a carer or loved one

Please click link: I am referring on behalf of an organisation

I am a Speech and Language Therapist

Prior to completing this referral form please read the pathways of support guidance on our website – https://www.aphasiasupport.org/make-a-referral/

For further information on this please email us on info@aphasiasupport.org or phone 01924 562443.

Client Details

First Name

Last Name

Gender

Age group

Street Address

Street Address Line 2

City

County

Postal Code

Birth Date

NHS number (please do not add any spaces between the numbers)

Date of Aphasia/Apraxia onset

Phone Number (please do not add any spaces between the numbers)

Mobile Number (please do not add any spaces between the numbers)

Preferred Communication Method(s)

Phone

Postal Mail

SMS

GP surgery address:

GP surgery phone number (please do not add any spaces between the numbers)

Does the person have any health conditions we should be aware of?

If yes, what support does the person require?

Have you visited the home of the person you are referring to us?

Yes

Aphasia Support’s volunteers visit clients at home to help improve communication.

They are often alone. If you have any concerns that the client’s home environment is unsuitable for lone working,
please detail the nature of these below (information regarding parking arrangements, key safe codes,
local public transport links or specific directions for difficult to find properties is also valuable)

Carer's Name and Relationship

Carers Phone Number (please do not add any spaces between the numbers)

Which software the client should use

Aphasia Therapy apps/software

Apraxia Therapy apps/software

Basic Communication aids

Other (Please state)

Does the client have internet access at home?

Yes

Does the client have access to a compatible device?

Yes

Which compatible device?

Your Details

First Name of Referrer

Last Name of Referrer

Referrer Email address

Phone Number

Phone Extension

Referral Date

Referral Hospital/Organisation

Referral Hospital/Organisation (if not in list above)

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Yes

Background information

Expressive Aphasia

Receptive Aphasia

Apraxia

Cause of Aphasia?

Other cause of Aphasia

Background on client

Please provide detailed medical history where possible, a copy of an assessment report can be attached to this form if it is easier to provide this detail.

Auditory comprehension

Spoken output

Written comprehension (reading)

Written output (writing/spelling)

Communication goal and suggested exercises (specify exercises on therapy apps if able/appropriate)

Would the carer be interested in receiving support from Aphasia Support?

Upload supporting information - e.g. assessment report

One file only.
3 MB limit.
Allowed types: pdf, doc, docx.

Referring to the pathways of support guidance on our website which pathway option do you feel is most appropriate for the person you are referring? Select all that apply.

Stage 1

Stage 2

Stage 3 (Aphasia Cafes)

Please complete this section to the best of your abilities giving all information you feel would help us to provide support.