WCUSD #5 Speech/Language Teacher Referral Form

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Email *

STUDENT NAME *

DATE OF BIRTH *

YYYY

TEACHER NAME

GRADE *

REFERRED BY *

Parent

Teacher

Other

REASON FOR REFERRAL - You may check more than one area of concern. *

ARTICULATION/PHONOLOGY: Child's speech is difficult to understand. The child mispronounces or leaves off sounds.

RECEPTIVE LANGUAGE : Child has difficulty understanding spoken language. Child does not understand meanings of grade appropriate vocabulary. Child had difficulty following spoken directions.

EXPRESSIVE LANGUAGE: Child shows challenges expressing ideas or thoughts or asking for help. Child speaks in short sentences with lack of elaboration on topics. When speaking in sentences, child will leave off small words such as "the" ."is", "to" or leaves off word endings such as plurals. Child has a diffucult time finding words, even with words the child is familiar with. Child uses unusual word order when speaking.

VOICE: The child has unusually loud or soft speaking voice. Child has an unusual quality to his/her voice (i.e. hoarseness, strained, breathiness)

FLUENCY/STUTTERING: Child frequently stutters when speaking in a variety of situations. Child uses excessive "um", "uh", and other interjections when speaking. Child appears to experience "blocks" or unable to get a sound or word out. Signs of tension such as eye blinking or hand clenching when speaking. Child speaks very fast, slow, or at an uneven rate.

PRAGMATIC LANGUAGE: Child has difficulty with conversational skills such as turn-taking, asking/answering questions, staying on topic, or initiating conversation. Child does not interact in an age-appropriate manner with peers.

Required

SERVICES CURRENTLY BEING RECEIVED BY STUDENT

Identified by Problems Solving Team

Reading Support

Special Education Services

Hearing Support

Physical Therapy

Occupational Therapy

Vision Support

Other

PLEASE DESCRIBE THE EDUCATIONAL IMPACT OF THE SPEECH/LANGUAGE CONCERNS. (ie. difficult to understand, impacts participation, student has been teased, etc.) PLEASE ALSO INCLUDE ANY OTHER COMMENTS OR NOTES WITHIN THIS SECTION.

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