MARGATE CITY PUBLIC SCHOOLS

SPEECH AND LANGUAGE REFERRAL FORM

STUDENT’S NAME_____________________________________DOB______________AGE_________

ADDRESS_____________________________________________________________________________

HOME PHONE_________________________________________________________________________

MOTHER_____________________________________FATHER_________________________________

                   First                                  Last Name                                  First                                  Last Name

ADDRESS, IF DIFFERENT  FROM ABOVE:

______________________________________________________________________________________

    Mother

______________________________________________________________________________________

   Father

SCHOOL____________________________H.R. TEACHER_____________________GRADE_________

RETAINED__________YES__________NO__________        GRADE (S)__________________________

DATE PARENT (S) NOTIFIED OF TEACHERS INTENTION TO MAKE REFERRAL______________

ATTENDANCE

        ABSENT OFTEN – YES_______  NO_______  TARDY OFTEN – YES ________ NO________

CURRENT EDUCATIONAL STATUS

(ATTACH COPY OF CURRENT REPORT CARD AND PROGRESS REPORTS, STUDENT’S

 SCHEDULE, RESULTS OF STANDARDIZED TEST & SUSPENSION OR DISCIPLINARY

 FORMS.)

CLASS PLACEMENT (AT TIME OF REFERRAL)

REGULAR______________________________ BASIC SKILLS______________________

        B.    ACADEMIC ACHIEVEMENT   (*USE TO DENOTE BELOW GRADE LEVEL FUNCTION)

                READING_____________________                LANGUAGE ARTS___________________

                SPELLING________________                MATH  ________________________

              SOCIAL STUDIES____________                SCIENCE_______________________

              OTHER__________________________________________________________


Areas of concern: Please check those characteristics that you have observed and are concerned about in this student, as he/she compares to same-aged peers. Please use the Comments section to give more insight about this student.

Articulation and Phonology

Receptive Language

Expressive Language

Voice

Speech Rate and Fluency

Pragmatic Language

Written Language/Phonemic Awareness

Classroom Interventions: Please check those that have been implemented with this child.


ADDITIONAL CONCERNS/COMMENTS

________________________________________________________________________

________________________________________________________________________

SIGNATURES OF ALL PERSONS HAVING INPUT INTO THIS REFERRAL

______________________________________                        _________________________________

______________________________________                        _________________________________

        

______________________________________                      _________________________________

______________________________________                     _________________________________

_____________________________________________________                _____________________

                                        TEACHER                                              DATE

_____________________________________________________                _____________________

                           PRINCIPAL                                              DATE

***PLEASE SEND TO THE DIRECTOR OF SPECIAL EDUCATION TO ENSURE TIME FRAME IS MET.

_____________________________________________________                _____________________

                DIRECTOR OF SPECIAL EDUCATION                              DATE

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