Speech Therapy Screening Form - ces
Speech Therapy Screening Form
Please remember that suspected speech disorders MUST have an adverse affect on learning in order for a student to qualify for public school speech therapy. For example, if a child misarticulates /s/, but participates in oral activities and his/her grades are average to above average, may not an adverse affect does not exist. However, if (a) a child refuses to speak orally, (b) other children comment about the differences in the child’s speech, or (c) the teacher cannot understand the student, then an adverse affect may exists. The same requirements also apply to suspected language, voice or fluency (stuttering) disorders. Parents can also make a referral but the child’s problem(s) must be evident at school for a child to qualify for services through the public school. Remember, many times parents see things at home that are not apparent at school and/or do not interfere with the acquisition of basic education skills.
Return this form to Speech Pathologist after completion.
Teacher Making Referral: _______________________________________
Date of Screening Request: ______________________________________
Student’s Name: _______________________________________________
Student’s Age: _________________________________________________
Reason for screening request:
(Describe in detail student’s specific behavior which warrants screening and the adverse affect on education)
________________________________________________________________________
Date of Screening: _________________________
Speech Therapist Follow-up Response:
DATE
Teachers:
Attached you will find a referral/screening form to be used with students you suspect may qualify for Speech-Language services in the school. Please read over the form and let me know if you have any questions or concerns.
If you know of any students who may qualify for services, please complete the form and place it in my box.
Thank you,
NAME (Credentials)
................
................
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