DOI: 10.

1590/2317-1782/20152014158

Original Article Organization of the referral and counter-referral system in

Artigo Original a speech-language pathology and audiology clinic-school

Daniela Regina Molini-Avejonas1 Organização do sistema de referência e contrarreferência

Stephanie Falarara Estevam1
Maria Inês Vieira Couto1 de uma clínica-escola fonoaudiológica

Keywords ABSTRACT

Speech, Language and Hearing Sciences Objective: To analyze the effectiveness of the referral and counter-referral flow in a speech-language pathology
Triage and audiology clinic-school and to characterize the patients’ profiles. Methods: Evaluation, retrospective, and
Clinical Competence prospective study, in which 503 patient records, without age restriction, were selected from a clinic-school and
Referral and Consultation the following variables were analyzed: demographic information, speech and hearing diagnosis, and references.
Patients were distributed into two groups according to the referrals made: internal (G1, n=341) and external
(G2, n=162) to the clinic-school. Results: A prevalence of male subjects under 12 years of age and with
diagnosis of language disorders (primary and secondary) was found. It was observed that 83% patients in G1
were recalled for evaluation and speech therapy after an average of 7 months of waiting; and from the patients
in G2 that were contacted (n=101), 13.9% were summoned and are satisfied with the place indicated for therapy
after an average of 4 months of waiting. From those who did not receive care, 46% sought another service,
and of these, 72.5% were successful. Conclusion: The data show the effectiveness and appropriateness of
referrals made internally, suggesting that, when the team works together, the network operates more adequately.
However, in relation to external referrals, they did not reach the proposed goals, indicating a lack of speech-
language pathologists in public services and the low interest of patients in looking for other places of care.

Descritores RESUMO

Fonoaudiologia Objetivo: Analisar a eficácia do fluxo de referência e contrarreferência fonoaudiológico realizados em uma
Triagem clínica-escola e caracterizar o perfil dos usuários atendidos. Métodos: Estudo do tipo avaliativo, retrospectivo
Competência Clínica e prospectivo, no qual foram selecionados 503 prontuários de pacientes sem restrição de idade atendidos
Referência e Consulta numa clínica-escola e analisadas as seguintes variáveis: informações demográficas, hipótese diagnóstica
fonoaudiológica e conduta fonoaudiológica. Os pacientes foram distribuídos em dois grupos, segundo
os encaminhamentos realizados: internos (G1, n=341) e externos (G2, n=162) à própria clínica-escola.
Resultados: Prevaleceram os sujeitos do gênero masculino, com até 12 anos de idade e hipótese diagnóstica
fonoaudiológica de alterações de linguagem oral de origem primária e secundária. Foi observado que 83%
dos pacientes do G1 foram convocados para avaliação e terapia fonoaudiológica após, em média, 7 meses de
espera; e, que dos pacientes contatados do G2 (n=101), 13,9% foram convocados e estão satisfeitos com o
local indicado para terapia após, em média, 4 meses de espera. Daqueles que não conseguiram atendimento,
46% procuraram outro serviço, sendo que desses, 72,5% obtiveram êxito. Conclusão: Foi constatada a eficácia
e adequação dos encaminhamentos realizados internamente, sugerindo que quando a equipe trabalha com
objetivo comum, a rede funciona de maneira mais adequada. Entretanto, em relação aos encaminhamentos
externos, esses não atingiram as metas propostas, indicando a falta de fonoaudiólogos em serviços públicos e
o baixo interesse do usuário em buscar outros locais de atendimento.

Correspondence address: Study carried out at Speech-Language Pathology and Audiology Investigation Laboratory in Primary Health
Daniela Regina Molini-Avejonas Care, School of Medicine, Universidade de São Paulo – USP – São Paulo (SP), Brazil.
Rua Cipotânia, 51, Cidade Universitária, (1) Department of Physical Therapy, Speech-Language Pathology and Audiology and Occupational Therapy,
São Paulo (SP), Brasil, CEP: 05360-000. School of Medicine, Universidade de São Paulo – USP – São Paulo (SP), Brazil.
E-mail: danielamolini@usp.br Conflict of interests: nothing to declare.

Received: 08/25/2014

Accepted: 12/26/2015
CoDAS 2015;27(3):273-8
274 Molini-Avejonas DR, Estevam SF, Couto MIV

INTRODUCTION in the clinic-school and were seen at the Speech-Language

Pathology and Audiology Investigation Laboratory in Primary
Speech-language pathology and audiology screening is Health Care (LIFAPS) of the Department of Physical Therapy,
an important procedure performed to detect alterations in the Speech-Language Pathology and Audiology and Occupational
scopes of language, voice, cognition, hearing, orofacial motor Therapy of the School of Medicine of Universidade de São Paulo.
skills, and speech(1). Studies indicated that the early detection It was approved by the research ethics committee of the School
and rehabilitation of alterations can limit or minimize possible of Medicine of Universidade de São Paulo (No. 072/11). All
consequences(2). It is also satisfactorily cost-effective because it participants signed the informed consent at the time of screening.
does not require specialized equipment and allows referral for The patients who completed the screening in LIFAPS,
speech-language pathology and audiology therapy at the most regardless of age, gender, and place of residence, and those
appropriate health care level as soon as possible. And, coupled who were treated between 2010 and 2012 were included in the
with epidemiological studies, it helps defining the demand, the study. The only exclusion criterion was the patient or guardian
territorial diagnosis, and the implementation of appropriate not consenting participation in the study.
public policies where the services are provided(3,4). The medical records of 503 patients were divided into two
Speech-language pathology and audiology is included in the groups:
public services. Therefore, it is present in the Unified Health • Group 1 (G1; n=341): patients referred for care at the clinic
System (SUS), which works in health care networks, covering of the Speech-Language Pathology and Audiology course
the three levels of care according to the complexity of the equip- of Universidade de São Paulo;
ment used. Primary health care is characterized as the door to • Group 2 (G2, n=162): patients referred for care outside of the
SUS and acts as the organizer of the network, including protec- Speech-Language Pathology and Audiology course of
tion promotion, prevention, diagnosis, rehabilitation, and health Universidade de Sao Paulo.
maintenance actions(5,6). Medium and high complexity actions
require specialized professionals and technological resources The study comprised three stages. In stage 1 – demographic
that enable the diagnosis and the therapeutic process and are and speech-language pathology and audiology characterization
focused on the ambulatory and hospital sectors(7). of participants, a survey of the medical records was conducted,
Studies showed that health networks can provide a more and demographic information (gender and age) was collected,
effective and comprehensive care when they have a referral and and diagnosis and referrals were made. In stage 2 – analysis of
counter-referral system(8,9). Referral can be understood as the internal referrals of participants in G1, coordinators responsible
referral of a patient from primary care to a more complex ser- for the laboratories of speech-language pathology and audiol-
vice, when a more specialized care is needed. Counter-referral ogy research of the clinic-school of Universidade de São Paulo
occurs when the patient is referred back to the primary care were requested to collect information on the speech-language
level, in basic health units (10,11). pathology and audiology conduct performed at screening:
In this context, the Speech-Language Pathology and number of patients enrolled for service (including those in
Audiology Investigation Laboratory in Primary Health Care therapeutic care and those who have been assessed and are
of the Department of Physical Therapy, Speech-Language waiting for treatment); how many months these patients had
Pathology and Audiology and Occupational Therapy of the to wait to start therapy; and the number of patients who did
School of Medicine of Universidade de São Paulo is a clinic- not fit into the laboratory profile and were referred to other
school that provides public health care, performing speech- services after full clinical assessment. In stage 3 – analysis of
language pathology and audiology screenings and referrals to external referrals of participants in G2, the screened patients
speech-language pathology and audiology therapy in the clinic or their legal guardians were contacted by phone. A structured
itself (internal) and in other public health services (external). interview was conducted to obtain the following information:
In the national literature, several studies are available 1. Did the patient get speech-language pathology and audiol-
that describe the sociodemographic and speech-language ogy treatment in the referred service?
pathology and audiology profile of the screened population in 2. If so, how long did they wait to start therapy and what was
clinic-schools(12,13), but these do not verify the effectiveness of their level of satisfaction with the care received (satisfied
referrals made(13). or dissatisfied)?
This study aimed to analyze the effectiveness of referrals 3. If not, indicate why, and if the patient got treatment
in speech-language pathology and audiology held in a clinic- elsewhere.
school, specifically to outline the demographic and speech-
language pathology and audiology profile of the population The variables were categorized as follows:
served and to analyze the referral and counter-referral flow • Demographic: gender (male and female) and age groups
after the speech-language pathology and audiology screening. (from 1 day to 5 years and 11 months, 6 years to 12 years
and 11 months, 13 years to 17 years and 11 months, 18
METHODS years to 59 years and 11 months, and over 60 years);
• Diagnostic hypothesis: language disorder (characterized
This is an evaluative, retrospective, and prospective study, as primary); alteration in language characteristic of neuro-
which aims to analyze the referral of patients who sought treatment logical problem, autism spectrum disorder, and syndrome,

CoDAS 2015;27(3):273-8
Referral in Speech-Language Pathology and Audiology 275

language disorder due to hearing loss (characterized as Analysis of referrals made in G1 (internal referral)
secondary); alteration in orofacial myofunctional system;
voice alteration; phonological disorder; alteration in reading Of the patients who received internal referral (n=341),
and writing; alteration in fluency; more than one diagnosis; the majority was summoned for speech-language pathol-
no alterations in speech-language or hearing; and others; ogy and audiology evaluation and therapy (83%); the other
• Speech-language pathology and audiology conduct: inter- patients were referred from speech-language pathology and
nal and external referral. audiology research laboratories to services outside of the
clinic-school (17%), indicating that these laboratories could
Information on all variables was entered into a Microsoft® not provide service according to the actual needs of the pa-
Excel spreadsheet by year of collection (2010, 2011, and 2012) tient (or that their speech-language pathology and audiology
and subjected to statistical analysis. profile did not meet the laboratory’s inclusion criteria). The
average waiting time for patients to start speech-language
RESULTS pathology and audiology therapy at the clinic itself was equal
to 7 months (Figure 1).
Demographic and speech-language pathology and
audiology profile Analysis of referrals made in G2 (external referrals)

In G1 (n=341), a predominance of males (n=226) and of the Of the patients who received external referrals (n=162),
age group with children up to 5 years and 11 months (n=113) contact by telephone was not possible with 61 (37.65%) patients
was observed. And, in G2 (n=162), a predominance of males or guardians, as the phone number did not match the number
(n=105) and of the age group between 6 years and 12 years provided, or they did not answer the phone after several at-
and 11 months (n=82) was observed (Table 1). tempts, or the phone number did not exist.
On the diagnostic hypotheses, G1 was found to have a
predominance of alteration in language, be it primary or
due to other diseases (frequency of occurrence of 29.9%), Table 2. Distribution of the diagnostic hypotheses of 503 patients, by
followed by phonological disorder (19.6%), alteration in groups
voice (13.8%), and alterations in orofacial myofunctional
Group 1 Group 2
system (Table 2).
Variables (internal referral) (external referral)
In G2, a predominance of more than one diagnostic
n (%) n (%)
hypothesis (17.9%) was observed, followed by phonologi-
cal disorder (11.7%) and alteration in language (11.7%). A Alteration in language
frequency of 33.8% primary alterations in language coupled characteristic of 23 (6.7) 9 (5.5)
with those resulting from other diseases (secondary) was neurological problem
found in this group. Alteration in language
Speech-language pathology and audiology diagnostic hypothesis

characteristic of Autism 35 (10.3) 5 (3.1)

Spectrum Disorder

Table 1. Demographic characterization of the 503 participants, by groups Alteration in language

8 (2.3) 14 (8.6)
characteristic of syndrome
Group 1 Group 2
Variables (internal referral) (external referral) Alteration in language 34 (10) 19 (11.7)
n (%) n (%)
Language disorder due to
2 (0.6) 8 (4.9)
Gender hearing loss
Female 115 (33.7) 57 (35.2) Alteration in the orofacial
43 (12.6) 19 (11.7)
Male 226 (66.3) 105 (64.8) myofunctional system

Age group Alteration in voice 47 (13.8) 1 (0.6)

Up to 5 years and 11 Phonological disorder 67 (19.6) 25 (15.4)
113 (33.1) 47 (29.1)
months
Alteration in reading and
6 years to 12 years 26 (7.6) 19 (11.7)
110 (32.3) 82 (50.6) writing
and 11 months
13 years to 17 years Alteration in fluency 33 (9.7) 3 (1.8)
15 (4.4) 18 (11.1)
and 11 months
More than one diagnosis 22 (6.5) 29 (17.9)
18 years to 59 years
87 (25.5) 14 (8.6)
and 11 months No alterations in speech-
1 (0.3) –
language or hearing
Above 60 years 16 (4.7) 01 (0.6)
Total 341 (100) 162 (100) Others – 11 (6.8)

CoDAS 2015;27(3):273-8
276 Molini-Avejonas DR, Estevam SF, Couto MIV

Of the 101 patients contacted, 13.9% were summoned Most of the G2 patients contacted could not get treatment
to therapy and waited an average of 4 months for the begin- in the location they were referred to (86.1%) (Figure  2),
ning of treatment. Among these, 86.1% patients reported and provided several reasons for this: there was no open-
being satisfied with the care provided in the place they were ing (25.3%), no interest of the patient or guardian to seek
referred to (Figure 2). the indicated institution (22.9%), the patient’s name is
on the waiting list for assessment or on the call list for therapy
(13.8%), the institution did not fit the profile established
G1
by the patient’s speech-language pathology and audiology
n=341 (100%) diagnostic hypothesis (11.5%), the institution was too far
from the patient’s house (8.1%), hours of operation were
incompatible with the patient’s activities (4.6%), there was
no speech-language pathologist on the institution (4.6%), and
other reasons (9.2%).
Still, regarding the patients contacted who failed to get an
opening at the institution they were referred to (n=87), 46%
Summoned for Not summoned (n=40) sought another institution for therapy; and, of these,
evaluation for evaluation 72.5% (n=29) got speech-language pathology and audiology
n=283 (83%) n=58 (17%) therapy in basic health units (31%), through health insurance
(24.1%) or other institutions (20.7%) (Figure 3).

Figure 1. Flowchart of patients in G1 Others

BHU
(20.70%)
(31%)

G2
n=162
patients
Institution
(20.70%)

Insurance
Patients Patients not Private (24.10%)
contacted contacted (6.90%)
n=101 (62.35%) n=61 (37.65%)

Caption: BHU = Basic Health Unit

Figure 3. Distribution of places where patients in G2 sought care (n=40)

Summoned Not summoned

n=14 (13.97%) n=87 (86.1%)
DISCUSSION

To analyze the effectiveness of speech-language pathology

and audiology referrals made in LIFAPS, 341 patients in G1
and 101 in G2 were monitored, totaling 442 patients.
Sought care in Did not seek care It was evidenced that the demographic profile of the total popu-
another institution in other institution
n=40 (46%)
lation (n=503) consisted of mostly male patients, what we know is
n=47 (54%)
a reality in speech-language pathology and audiology services(14,15),
and that may be related to slower brain maturation, genetic factors,
or social factors (child interaction with the environment they live
in), especially in regard to language disorders(4,12,13,16,17).
There was a predominance of children (under 12 years
Got care Did not get care
n=29 (72.5%) n=11 (27.5%) and 11 months old) with alterations in language (79.7%),
probably because parents and teachers of this age group
are more attentive to the development of oral and written
language(4,12,13,16,17). However, the long extension of this age
Figure 2. Flowchart of patients in G2 group may be related to the origin of the speech-language

CoDAS 2015;27(3):273-8
Referral in Speech-Language Pathology and Audiology 277

disorder, which can be developmental or acquired; to the time must be structured to assist the patient to find the appropriate
it took to the child’s guardian to realize and seek care; and to speech-language pathology and audiology therapy services.
the time it took to perform the screening(16). Children come In another context, the success of the few external referrals
to speech-language pathology and audiology screenings at an (14%) may be related to the availability of services at BHUs and
increasingly early age, but there are still a significant number their access by the population, such as the services offered and
of individuals seeking therapy later in life. This can occur due consultation hours(10). Therefore, for the referral and counter-
to lack of information (not knowing what is the role of the referral system to be effective, it is necessary to refer the patient
speech-language pathologist), erroneous guidance (parents are to the institution that meets their needs, have adequate resources,
advised by health and education professionals to wait for 5 and is close to their house, which is not an easy task. That said, it
years to seek care), and lack of professional speech-language is noteworthy that the institution that guaranteed speech-language
pathologists in the public service. pathology and audiology services the most were BHUs, showing
The predominant diagnostic hypotheses (primary and the importance of the speech-language pathologist in primary
secondary alterations in language) corroborate previous study, health care and in the counter-referral process.
which highlights the importance of a more homogeneous The relationship between the primary, secondary, and tertiary
classification of these to facilitate the comparison of survey health services is essential to the health care network to function
data(12). There is a lack of unanimity in national scientific properly(10,20). Often referrals are made without information on the
production on the nomenclature used in diagnostic hypoth- presence of a speech-language pathologist in the medical team
eses, which interferes in comparing the results of this study and on the profile serviced in the referred institution. Similarly,
with others. However, the categories selected for this study there is a need for more careful counter-referrals. Very few cases
facilitated the classification of this variable and are used in are referred to the BHUs after treatment in secondary or tertiary
the clinic-school. At the same time, language issues are ex- services, showing a failure in the health care network.
tremely complex, and labeling all the different situations that
are affected by this disorder simply as alterations in language CONCLUSION
would not be correct. A study with methodological rigor is
necessary for discussing this category. It can be concluded that when the service works in coordina-
For a long time, phonological and fluency alterations were tion between professionals in the primary, secondary, and tertiary
predominant in the clinic-school in question(14,18), but, for a few services, the referral and counter-referral processes occur in an ef-
years, alterations in language have been prevalent, showing that fective manner, and the individual’s right to health is guaranteed.
speech-language disorders can prevail differently over time and However, when that coordination does not happen, or is
that the population have a better understanding of the different faulty, coupled with the small number of speech-language
areas of expertise of a speech-language pathologist. pathologists in the public health system, the user has no access
Most individuals in G1 (83%) got care in the clinic-school’s to speech-language pathology and audiology therapy services.
internal laboratories, showing the effectiveness and suitability The need to improve the form adopted for external referrals
of the referral process performed. This is probably due to the made, either for referrals or counter-referrals, is noteworthy
adequacy of the instruments, procedures, and analysis of the because referral letter used and the list of referral institutions
information used in screening(13), ease of articulation between available were not sufficient to support the completion of the
professionals in the clinic and the LIFAPS team. process. In addition, family awareness about the importance of
In contrast, only for a minority of individuals contacted seeking the referred service should be improved.
in G2 (13.9%), referral was effective. The reasons may be Further study is suggested to monitor the referrals and
related to reduced number of speech-language pathologists counter-referrals in speech-language pathology and audiology
in public health services, which increases the waiting time services, so that the principles of SUS can be followed.
for service and reduces the number of openings; and also the
lack of organization and communication of the professionals
*DRMA was responsible for the project’s design and planning, analysis
who make up the health care network(10,16,19,20). The number of and interpretation of data, contributed significantly to the drafting of
speech-language pathologists in public health services is still the manuscript and to the critical review of the content, and was also
very low. The premise of one speech-language pathologist for responsible for the last corrections; SFE participated in the collection,
every 10,000 inhabitants is not put in practice(21,22). analysis and interpretation of data, contributed significantly to the drafting
In cases in which there was no interest in seeking the in- of the manuscript and participated in the approval of the final version of
the manuscript; MIVC helped in the analysis and interpretation of data,
stitution indicated (n=20), it is possible that the family did not contributed to the drafting of the manuscript and to the critical review of the
realize the impact of the speech-language disorder in the social content and participated in the final approval of the manuscript.
performance of those patients, and how therapy could reverse
and/or minimize this impact. Guidance to the patient should
always be given clearly and cautiously during screening, that is, REFERENCES
to make sure that the patient or guardian understands what the
1. Friderichs N, Swanepoel D, Hall JW. Efficacy of a community-based
alterations are, their consequences, and the referrals; and inform infant hearing screening program utilizing existing clinic personnel
that the referral given is one alternative for the patient, because in Western Cape, South Africa. Int J Pediatr Otorhinolaryngol.
the care sectors of basic health units (BHUs) and institutions 2012;76(4):552-9.

CoDAS 2015;27(3):273-8
278 Molini-Avejonas DR, Estevam SF, Couto MIV

2. Lipay MS, Almeida EC. A fonoaudiologia e sua inserção na saúde 13. Barros PML, Oliveira PN. Perfil dos pacientes atendidos no setor de
pública. Rev Ciênc Méd. 2007;16(1):31-41. fonoaudiologia de um serviço público de Recife-PE. Rev CEFAC.
3. Pires MRGM, Göttems LBD, Cupertino TV, Leite LS, Vale LR, Castro 2010;12(1):128-33.
MA, et al. A utilização dos serviços de atenção básica e de urgência no 14. Silva GMD, Couto MIV, Molini-Avejonas DR. Risk factors identification
SUS de Belo Horizonte: problema de saúde, procedimentos e escolha dos in children with speech disorders: pilot study. CoDAS. 2013;25(5):456-62.
serviços. Saúde Soc. 2013;22(1):211-22. 15. Samelli AG, Rondon S, Oliver FC, Junqueira SR, Molini-Avejonas DR.
4. César AM, Maksud SS. Caracterização da demanda de fonoaudiologia Referred speech-language and hearing complaints in the western region
no serviço público municipal de Ribeirão das Neves - MG. Rev CEFAC. of São Paulo, Brazil. Clinics. 2014;69(6):413-9.
2007;9(1):133-8. 16. Mandrá PP, Diniz MV. Caracterização do perfil diagnóstico e fluxo de um
5. Cavalheiro MTP. Fonoaudiologia e saúde da família. Rev CEFAC. ambulatório de fonoaudiologia hospitalar na área de linguagem infantil.
2009;11(2):179-368. Rev Soc Bras Fonoaudiol. 2011;16(2):121-5.
6. Molini-Avejonas DR, Mendes VLF, Amato CAH. Fonoaudiologia e 17. Diniz RD, Bordin R. Demanda em Fonoaudiologia em um serviço
Núcleos de Apoio à Saúde da Família: conceitos e referências. Rev Soc público municipal da região Sul do Brasil. Rev Soc Bras Fonoaudiol.
Bras Fonoaudiol. 2010;15(3):465-74. 2011;16(2):126-31.
7. Spedo SM, Pinto NRS, Tanaka OY. O difícil acesso a serviços de média 18. Hermogenes C, Rocha CH, Molini-Avejonas DR, Wenceslau LGC,
complexidade do SUS: o caso da cidade de São Paulo, Brasil. Physis. Couto MIV, La Torre R. Perfil dos pacientes atendidos na triagem
2010;20(3):953-72. fonoaudiológica em uma clínica-escola: estudo piloto. Rev Soc Bras
8. Méio MDBB, Magluta C, Mello RR, Moreira MEL. Análise situacional Fonoaudiol. 2011;16(Suplemento). Disponível em http://www.sbfa.org.
do atendimento ambulatorial prestado a recém-nascidos egressos das br/portal/suplementorsbfa..
unidades de terapia intensiva neonatais no estado do Rio de Janeiro. 19. Bazzo LMF, Noronha CV. A ótica dos usuários sobre a oferta de
Ciênc Saúde Coletiva. 2005;10(2):299-307. atendimento fonoaudiológico no Sistema Único de Saúde em Salvador.
9. Chiavagatti FG, Kantorski LP, Willrich JQ, Cortes JM, Jardim Ciênc Saúde Coletiva. 2009;14(Suppl 1):1553-64.
VMR, Rodrigues CGSS. Articulação entre Centros de Atenção 20. Tôrres AKV, Sarinho SW, Feliciano KVO, Kovacs MH. Acessibilidade
Psicossocial e Serviços de Atenção Básica de Saúde. Acta Paul Enferm. organizacional de crianças com paralisia cerebral à reabilitação motora
2012;25(1):11-7. na cidade do Recife. Rev Bras Saúde Matern Infant. 2011;11(4):427-36.
10. Serra CG, Rodrigues PHA. Avaliação da referência e contrarreferência no 21. Lessa FJ, Miranda GMD. Fonoaudiologia e saúde pública. In: Britto
Programa Saúde da Família na Região Metropolitana do Rio de Janeiro ATBO, organizador. Livro de fonoaudiologia. São José dos Campos:
(RJ, Brasil). Ciênc Saúde Coletiva. 2010;15(Suppl 3):3579-86. Pulso Editorial; 2005.
11. Rodrigues LA, Vieira JDM, Leite ICG. Avaliação do fluxo de referência 22. Conselho Regional de Fonoaudiologia 2ª Região, São Paulo [Internet].
para um centro de especialidades odontológicas implantado em cidade Atuação Fonoaudiológica nas Políticas Públicas: subsídios para
de médio porte na região Sudeste. Cad Saúde Colet. 2013;21(1):40-5. construção, acompanhamento e participação dos fonoaudiólogos.
12. Costa RG, Souza LBR. Perfil dos usuários e da demanda pelo serviço Conselho Regional de Fonoaudiologia. São Paulo: CRF; 2006.
da clínica-escola de fonoaudiologia da UFBA. Rev Ciênc Méd Biol. Disponível em: http://www.fonosp.org.br/publicar/publicacoes/atuacao_
2009;8(1):53-59. fonoaudiologica_2a_rev.pdf

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