Speech and Language Concerns Referral Packet

[Pages:4]Teacher Name:__________________________

Speech and Language Concerns

Student Name:____________ Grade:_______________ Date of Birth:__________

Dear Teacher, Here are some steps to take if you feel that a student has difficulty with

communication. This paperwork is your data for a referral process. The hope is that the problem can be corrected in the classroom. If not, then we request an evaluation.

1. Is student's HEARING OKAY? ( check with nurse)

Date tested: ____________ Outcome: GOOD HEARING

HEARING LOSS

2. Is more than one language spoken in the home?

YES

NO

3. Do parents have difficulty understanding their child?

Date interviewed: _____________ Parent Response:__________________________________ __________________________________________________

4. Teacher please describe your concern:

7 minutes

________________________________________

Which of these applies to your student?

1. I can't understand the words that my student uses.

Have the student repeat the words from the Sound Chart, page 2 or 3.

2. My student doesn't speak enough, is confusing, or can't understand me.

Write examples of what your student says

10 minutes



English Sound Chart

1. Ask the student to repeat these words. 2. CIRCLE correct words 3. CROSS OUT incorrect words and write what the student says

SOUND AGE

p

4+

b

4+

m

4+

n

4+

h/w 4+

f

5+

t

5+

d

5+

k

5+

g

5+

y

5+

ng 7+

v

7+

r

7.5+

er 7.5+

l

7.5+

s

7.5+

sh 7.5+

zh 7.5+

ch 7.5+

j

7.5+

z

8.5+

soft th 8.5+

hard th 8.5+

WORDS pig, apple, cup bunny, baby, crib mad, hammer, thumb no, funny, fan

hat, wet food, coffee, off toys, water, bat doll, middle, bed king, pumpkin, rake goat, wagon, bag yellow, crayon

finger, ring vote, oven, stove

rat, green early, nurse, fur lion, pillow, tall sock, pencil, kiss shoe, fishing, fish

measure chair, teacher, lunch jelly, pajamas, orange

zoo, puzzle, toes thumb, bathtub, tooth

those, brother



Page 2/4

Spanish Sound Chart

1. Ask the student to repeat these words. 2. CIRCLE correct words 3. CROSS OUT incorrect words and write what the student says

SOUND AGE

p

3+

b

3+

m

3+

t

4+

k

4+

n

4+

l

4+

f

4+

ll (/y/) 4+

w

4+

d

5+

ch

5+

g

5+

?

5+

r

5+

s

6+

rr

7+

WORDS pato, payaso, papalote

beso, globo, blanco mio, amigo, mantequilla

taco, tomate, tortuga queso, chocolate, crema

no, mano, jugando luces, colores, azul, playa

foco, elefante, flor lluvia, olla, cosquilleo hueso, agua, guantes dedo, dormido, dibujando

chile, muchacha gato, pegado, grande

?and?, a?o caro, coraz?n, brincar sol, payasos, misma

rosa, carro



Page 3/4

For m

Language Information

A child can have difficulty communicating for a variety of reasons. Go through the boxes below and see if the child is able to do the following. Record information in each box or put a check if you have no concerns.

Expressive Language (the student says...)

Child Says:

Receptive Language (the student understands...)

Follows Directions:

Uses subject-verb-object (I eat grapes) Simple Commands (come here)

Syntax

Uses descriptive words with nouns (big bear)

Has a normal order to storytelling?

1 part (give me the pen)

2 parts (put the blue pen in the green box)

Uses plurals (Ex. Apples)

Understands past tense verbs:

Uses 1st and 3rd person (I eat, she eats)

-irregular (ran)

-regular (jumped)

Morphology

Describes objects: Name: (shoe) Category: (clothes) Function: (you wear them) Attribute: (adjectives of the noun)

Makes eye contact Takes turns in conversation Maintains a topic in conversation

Answers Questions: Which? (has less/more) Who? What? When? (time) Where? Yes/No

Understands pointing Responds appropriately to requests

Content Semantics

Use Pragmatics



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