Referral for Support | Portal: Aphasia Support

Are you making a referral for someone based in Yorkshire, Blackburn or Nottingham?

Yes

Thank you for your interest. At present, we are only able to accept referrals in Yorkshire, Blackburn and Nottingham. We are working hard to meet the demand for our services and to expand our support across the UK.
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Please know that we are only accepting one-to-one referrals in West Yorkshire, Harrogate and Barnsley. We are accepting group referrals into our Aphasia Cafe’s located in Wakefield, Leeds, Doncaster, Barnsley, Harrogate, Kirklees, Calderdale, Blackburn, Nottingham and Online.

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

Date of Aphasia/Apraxia onset

Phone Number

Mobile Number

Preferred Communication Method(s)

Phone

Postal Mail

SMS

GP surgery address:

GP surgery phone number:

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

If yes, what support does the person require?

Aphasia Support’s volunteers support our service delivery by visiting clients at home to facilitate video
calls via Zoom. 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)

Background information

Expressive Aphasia

Receptive Aphasia

Apraxia

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

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