Speech/Language Support Screening Referral
To help us identify the child's educational needs as they relate to his/her speech/language skills, please take a few moments to share your information in the areas listed below. Your input will be important in helping us plan an appropriate educational program and, if recommended, a Speech/Language Support Program.
Your Email Address:
Student's Date of Birth:
1. Please select each service that the child currently receives:
Instructional Support Team (IST)
Title I Reading Support
Occupational Therapy (OT)
English as a Second Language (ESL)
Special Education Services
None of the Above
2. Please select the reason(s) for speech/language screening referral:
3. Please select any/all LANGUAGE concerns you have for the child:
Semantics/Vocabulary Skills: labeling, categories, inference
Syntax/Grammar Skills: sentence structure, word order, verb tenses
Auditory Skills: word finding, sequencing, following directions
Pragmatics/Social Language Skills: turn taking, topic maintenance
I have no language concerns for the child.
4. Please select any/all FLUENCY concerns you have for the child:
Repetitions: repeats sounds, syllables, words, phrases
Prolongations: prolongs sounds, syllables, words, phrases
Blocks: tries to speak, but nothing comes out
Struggle Behaviors: grimacing, head jerking, eye blinking
I have no fluency concerns for the child.
5. Please select any/all ARTICULATION concerns you have for the child:
Speech is unitelligible
Speech is intelligible with careful listening
Speech is intelligible but noticeably in error
I have no articulation concerns for the child.
6. Please select any/all VOICE concerns you have for the child:
Abnormal quality or pitch
Dysphonia: lack of voicing while trying to speak
I have no voice concerns for the child.
7. Please provide any additional details related to your reason(s) for referral, language, fluency, articulation, and/or voice concerns you identified in the previous questions.
8. Does the speech/language problem have an adverse effect on the child's educational performance?
9. If you answered yes to question #8, please explain how the speech/language problem adversely affects the child's educational performance.
Thank you for completing this speech/language support screening referral!
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