TBCS Speech-Language Screening Request Form 2023-2024
Kindly complete the following form for the student you are referring for a speech-language screening.

Please fill this form out entirely, as these are important details for the SLP to know before scheduling a screening. If upon SLP review forms are found to be submitted incompletely, the unknown information will be requested, prior to coordinating an observation.

Thank you for your thoroughness to most efficiently refer this student for communication screening!

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Email *
Please read the following statements and mark your understanding/agreement.

I understand that I am submitting a request to the Speech-Language Pathologist (SLP) for a speech and/or language screening for the student whose information I list in this form. This request will be processed by the SLP at their earliest convenience.

I acknowledge that speech refers to how we say sounds and words, including articulation (the speech sounds we use), voice (quality of our speech), and fluency (rhythm or flow of our speech). Language refers to our understanding and use of communication, the words we know and use, and how we use them to share ideas. I can click here for more information.

The SLP will coordinate with the student's family and team in order to discuss screening (if permitted). 

I understand that a screening is a brief observation or assessment of a person's speech and/or language skills. A screening is meant to give initial impressions and identify if a comprehensive speech-language evaluation may or may not be warranted

I understand that the SLP will communicate with the student's caregiver(s) in order to request permission, schedule and communicate results of the speech-language screening.

I understand that the result of a speech-language screening will only be a recommendation of the next step to consider, and does NOT mean that a student will undergo the special education evaluation process or receive special education speech-language services.  The considerations for a comprehensive evaluation and individualized education program are separate processes that require consent and team meetings at each step.

You may see Alaska Procedural Safeguards at  https://education.alaska.gov/sped for more information on special education processes. 
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Student's First & Last Name: *
Student's Date of Birth:
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Student's ID Number (if known)
Student's Current Grade (2023-2024)
*
Why am I referring this student for a speech-language screening?
I became concerned about the student's communication skills (give a rough guess at the day, primarily looking for the month/year) *
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How is the child performing academically? *
Below Grade Level
At Grade Level
Above Grade Level
Reading
Writing
Math
Communication Areas - What are the concerns and observations?
Concerns in communication could be in one or more of the various areas of communication development including: speech sound production and intelligibility, expressive language (speaking), receptive language (listening/processing what is heard), speaking fluency, speaking voice, social communication, and communication behaviors.
Speech Sound Production *
Required
Speech Sound Production comments:
Expressive Language (speaking) *
Required
Expressive language comments:
Receptive Language (listening):
Receptive language comments:
If "appears to have difficulty hearing" was marked, when was the last hearing screening, per parent report? **please ask parents/guardian this question, if this is a checked area of concern** *
Speech Fluency *
Required
Speech Fluency comments:
Speech Voice *
Required
Speech voice comments:
Social Communication *
Required
Social skills comments:
Communication Behaviors *
Required
If communication behaviors of "not able to communication basic wants/needs" was marked, list 3 specific examples when communication requires adult support (if this is not a concern type "n/a"): *
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