Dundee Community School District
What is the student's name?
Who is making the Referral? (Staff member's name)
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
How is this student's communication difficulty impacting them in the classroom?
(e.g., Spelling, Reading Comprehension, Writing, Socially, Speaking in class etc.)
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.)
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