<p> NIAGARA CATHOLIC DISTRICT SCHOOL BOARD SPEECH-LANGUAGE SERVICES REFERRAL FORM</p><p>SECTION 1 – TO BE COMPLETED BY CLASSROOM TEACHER </p><p>School Date Student Name Date of Birth Grade Teacher Mother/Father Guardian Home Phone Work Phone</p><p>1. Please check only if student demonstrates difficulty (ies) in any of the following areas: Area of Difficulty List Specific Problems Strategies Used  Articulation</p><p> 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</p><p>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</p><p>5. List involvement activities of the Resource Teacher (e.g. individual, small group, etc) ______</p><p>6. List other staff members involved with this student (e.g. EA, Literacy Teacher, CYW, etc) ______SECTION II – TO BE COMPLETED BY PARENT/GUARDIAN </p><p>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. </p><p>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 </p><p>*Submit copies of any Speech - Language reports Assessment(s) No Yes Where When Results Hearing Central Auditory Processing Vision Dental </p><p>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 </p><p>______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 ____</p><p> 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)</p><p>CONSENT FORM</p><p>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: ______</p>