Prior to completing this referral form please read the pathways of support guidance on our website – 

We are currently accepting new one-to-one referrals for options 1 and 2 of our pathway of support in Leeds, Wakefield and Barnsley. We hope to expand into other areas from August. We are accepting referrals into stage 3 aphasia cafes across all our current areas.

Please Note: As a result of funding difficulties, from April 2024 we are charging a modest amount to receive one-to-one support from the charity. A free 45 minute consultation with a Speech and Language Therapist will be provided. If the client agrees to proceed with support, there will be an initial fee of £40 made payable at the matching appointment, followed by a £5 monthly charge towards funding the fortnightly one-to-one sessions (£2.50 per session for 12 sessions over a 6 month period).

For further information on this please email us on or phone 01924 562443.

Client Details
Preferred Communication Method(s)
Does the person have any health conditions we should be aware of? Eg Epilepsy
Referral for Support
Which software the client should use
Does the client have internet access at home?
Does the client have access to a compatible device?
Would you like to receive the Aphasia Support newsletter?
Would the client/carer require support to access video calls?
Where appropriate/available, can the client travel to a community venue for support?
Background information
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.
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.
Please complete this section to the best of your abilities giving all information you feel would help us to provide support.