Get in touch Find out what services you can access in your area or check out your nearest CPL centre. Call us 1800 275 753 Our Location Client name: Client's date of birth: Reason for referral: Available government funding source NDIS plan Home care package DS/HACC Continuity of Care funding (65+) None Does the client prefer to use FFS for this referral? Yes No Preferred outcome (if known) e.g. assessment, new wheelchair, transfer docs: Checklist completed by: Relationship to client: Service, location and client address (e.g. Support at home - Fig Tree Pocket, 17 Rosella St, Fig Tree Pocket): Who to contact to set appointments (key contact name): Relationship of key contact to client: Key contact details - phone: This screening checklist needs to be filled out in consultation with someone who is familiar with the client’s mealtime abilities. It is mandatory to make a referral to CPL speech and language pathologist when: A) any items from 1-5 have been rated ‘Occasionally’ or ‘Often’, or B) 3 or more checklist items in total have been rated ‘Occasionally’ or ‘Often. Referral to, and assessment by, a speech and language pathologist may still be warranted when the mandatory criteria has not been met. In this instance, a referral to a speech and language pathologist should be offered to the client/family. Please selectI accept 1. Does the person choke during eating and drinking e.g. changes in colour (blue in face and around lips), cessation of breathing, obvious distress? Please selectNeverOccasionally Often 2. Does the person cough before, during or after eating or drinking? Please selectNeverOccasionally Often 3. Does the person have a wet/gurgly voice during or soon after eating/drinking? Please selectNeverOccasionally Often 4. Does the person’s breathing pattern change during eating and drinking e.g. becomes faster and/or shortness of breath? Please selectNeverOccasionally Often 5. Does the person show anxiety and/or have difficulty swallowing certain types of food, drink, or medication? Please selectNeverOccasionally Often 6. Does the person have difficulty chewing foods? Please selectNeverOccasionally Often 7. Does the person have food/fluid remaining in their mouth after swallowing? Please selectNeverOccasionally Often 8. Does it take more than 30 minutes for the person to finish eating a meal? Please selectNeverOccasionally Often 9. Does the person have chest infections? Please selectNeverOccasionally Often 10. Does the person have any vomiting or reflux when eating and drinking? Please selectNeverOccasionally Often 11. Does the person require physical assistance from others to eat/drink? Please selectNeverOccasionally Often 12. Are there concerns about the client’s weight and/or signs of dehydration such as dry skin, dry mouth, concentrated urine, constipation. Other referrals to GP/supporting doctor and / or dietitian should be considered. Please selectNeverOccasionally Often 13. Describe the difficulties the person is having: Submit form Leave this field blank
