Speech/Language Referral Form
What is the student's name?
Who is making the Referral? (Staff member's name)
List the school district and the student's grade.
What are your concerns with this student's communication?
Articulation (How the student pronounces words)
Language (How the student understands and uses words to communicate)
Fluency (Stuttering, difficulty getting words out)
Voice (Pitch, loudness, hoarsness, breathiness, etc.)
Pragmatics (How the student uses language socially)
If there are articulation/phonology concerns, please indicate specific speech sounds that the student has difficulty with.
SH, CH, J
I am not sure
Please share any additional information you think would be relevant to this student's referral. (e.g., I believe this student already has an IEP for academics, the student's parents don't speak English, the student seems very shy and reluctant to speak in class, etc.)
If you have already provided interventions, please check all that apply concerning the setting and frequency.
2-3 times per week
Have not attempted; would like for the Speech Pathologist to help first.
If you have already provided interventions, please check the ones you have tried or are providing for Articulation.
Model correct sounds/words by repeating. (S: I wuv tool. T: Oh, you love school.)
Give the student feedback on pronunciation during reading or spelling. ("I heard you say wabbit. Rabbit starts with "R". Listen and watch how I say Rabbit.")
Describe how your mouth moves when you make the sound. (The "F" is the bunny teeth sound. See how we put our top teeth on our bottom lip and blow air?)
Individual or small group sound activities: Have the student practice saying the sound while engaging in educational activities (writing the sound/word, reading or repeating word lists, and rhyming words (take/steak, tape/cape)).
Ask the student to speak slower. ("I'm having trouble listening when you talk fast. Would you say it again a bit slower?)
Give the student a consistent visual cue for the sound when reading or repeating spelling words. (Example: point to the throat for the "k" sound).
If you have already provided interventions, please check the ones you have tried or are providing for Language.
Choose random words during reading or writing activities. Have the student state an antonym, synonym, or two different meanings.
Have the student answer “WH” and “How” questions after reading a story.
Select 4-5 random sentences from a story and ask the student to repeat them back to you. If mistakes are noted, model correct grammar.
Ask the student to retell the story in correct sequence using specific details, correct grammar, and appropriate vocabulary.
Provide the student visual aids when giving directions.
If you have already provided interventions, please check the ones you have tried or are providing for Stuttering.
Show you are listening. Do not interrupt the student or speak for him/her. Maintain eye contact.
Model appropriate pacing. Speak calmly and clearly with slow, easy speech.
Allow appropriate wait time for student to respond. It is sometimes best to call the student’s name before being asked the question.
Consider having the student give the presentation privately or only to a small group. Allow “fillers” such as uh, and, well, like, you see. This is common in people who have disfluencies.
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