Niagara Catholic District School Board

NIAGARA CATHOLIC DISTRICT SCHOOL BOARD SPEECH-LANGUAGE SERVICES REFERRAL FORM

SECTION 1 – TO BE COMPLETED BY CLASSROOM TEACHER

School Date Student Name Date of Birth Grade Teacher Mother/Father Guardian Home Phone Work Phone

1. Please check only if student demonstrates difficulty (ies) in any of the following areas: Area of Difficulty List Specific Problems Strategies Used  Articulation

 Voice  Hoarseness  Nasality  Dysfluency (Stuttering)  Receptive Language  Vocabulary  Understanding verbal messages  Basic Concepts (spatial, temporal, quantity)  Following Directions  Expressive Language  Grammar  Vocabulary  Message organization/sequencing  Attention  Short-Term Memory  Reading  Comprehension  Oral  PM Benchmark level ______ Phonemic Awareness  Hearing  Hearing Aids/ Cochlear Implant  Uses an FM/Sound Field System  Additional Informational

2. Does the student have difficulties in other skill areas: Gross Motor ______Fine Motor ______Social ______Behaviour ______Emotional ______Academic ______3. Has the student participated in the following programs? no ٱ yes ٱ no Phonographix ٱ yes ٱ no Orton Gillingham ٱ yes ٱ Reading Recovery Program Describe: ______discharged ٱ monitor ٱ ongoing ٱ , no If yes ٱ yes ٱ ?Has there been involvement with ESL .4

5. List involvement activities of the Resource Teacher (e.g. individual, small group, etc) ______

6. List other staff members involved with this student (e.g. EA, Literacy Teacher, CYW, etc) ______SECTION II – TO BE COMPLETED BY PARENT/GUARDIAN

Has your child been seen or tested by any other individual or agency for any of the following? If so, please indicate, giving name, approximate dates and results.

Speech-Language Pathology ______Agency ______Date ٱ no ٱ Assessment yes ______Agency ______Date ٱ no ٱ Therapy yes Date Started______Date Finished______Agency ٱ no ٱ Waiting List yes

*Submit copies of any Speech - Language reports Assessment(s) No Yes Where When Results Hearing Central Auditory Processing Vision Dental

Please provide the following information:  Name of Paediatrician, if any ______no ٱ yes ٱ ? Were there any problems at pregnancy or at birth no ٱ yes ٱ ? Was your child born before the due date no ٱ yes ٱ ? Has your child been diagnosed with any developmental difficulties  Has your child ever been hospitalized? Describe: ______no ٱ yes ٱ ? Have there been any injuries to the head  When did your child start saying two-word sentences? ______(no Language (s ٱ yes ٱ ? Is a second language spoken at home no ٱ yes ٱ ? Has your child had a history of repeated ear infections in the first five years of life

______no If yes, date of surgery ٱ yes ٱ ? Has your child had tubes  Has your child had: Frequent colds ____ Allergies ____ Asthma ____ Attentional difficulties ____ Tonsils removed ____ Adenoids removed ____

 List any medications ______Include any other information you may feel will be relevant/helpful in the evaluation of your child’s communication needs (e.g. background history, other therapies, etc)

CONSENT FORM

Personal information on this form is collected under the authority of the Education Act, R.S.O. 1980, Chapter 129 and will be used to provide Speech-Language Services as required. I hereby consent for my child to receive an assessment of his/her speech and language needs by the Board Speech- Language Pathologist, as well as any subsequent programming or treatment recommended by the Speech-Language Pathologist. This assessment may include a hearing screening. I understand that it may be necessary for information to be accessed from my child’s OSR by members of the Speech-Language department, and/or to be discussed with other School Board professionals. Date: ______Signature of Parent/Guardian: ______