SPEECH PATHOLOGY REFERRAL REPORT
2018 LANGUAGE DEVELOPMENT CENTRE PLACEMENT
YEAR ONE
STUDENT DETAILS:
NAME: DOB:______GENDER: o Male o Female
CHRONOLOGICAL AGE AT TIME OF ASSESSMENT:____ CURRENT SCHOOL:______
IS THE CHILD AN AUSTRALIAN CITIZEN OR PERMANENT RESIDENT: o Yes o No
ADDRESS:
POST CODE: TELEPHONE NUMBER:
MONTH AND YEAR OF FIRST EVER S.P. CONTACT: DATE OF LDC REFERRAL:
PREVIOUS THERAPY: oNone – assessment only oMinimal contact/Indirect contact oRegular intervention
REFERRING AGENCIES: Who has initiated the referral? (please tick)
Parent Speech Pathologist Teacher School Psychologist Other (specify) ______
REFERRING SPEECH PATHOLOGIST: REFERRING PSYCHOLOGIST:
Name: Name:
Organisation: Organisation:
Address: Address:
Post Code: Post Code:
Phone: Fax: Phone: Fax:
Email: Email:
MOTHER’S NAME: FATHER’S NAME:
Siblings (names & ages)
Contact Phone Number (Business Hours) Mother: Father:
Case Worker / Carer (if applicable): ______
PARENT / CARER CONSENT
I have read the above details and declare them to be true and correct. I wish this application for placement at the
Language Development Centre to be considered. I understand that the referral does not guarantee placement. I am prepared to support and assist with my child’s educational program should she/he be accepted.
Signed Date
In order to assist the processing of referrals, please complete the following questions.
DOES THE CHILD HAVE:
1. An intellectual disability? Yes No
2. Severe epilepsy? Yes No
3. Autism or Asperger’s Syndrome? Yes No
4. Global Developmental Delay? Yes No
OTHER AGENCIES INVOLVED (if known):
o Paediatrician / Medical Officer - Contact Name:
o Developmental assessment completed and copy attached
o Occupational Therapist - Contact Name:
o Physiotherapist - Contact Name:
o Disability Services Commission (DSC) - Contact Name:
o National Disability Insurance Agency (NDIA) - Contact Name:
o Autism Association - Contact Name:
o The Ability Centre (formerly Centre for Cerebral Palsy) - Contact Name:
o School of Special Educational Needs Sensory (SSENS) - Contact Name:
o Other(s) - Contact Name:
TRANSPORT REQUIREMENTS: Note: this information is to help inform school planning only.
Transport information provided does not define or limit families' transport options upon enrolment.
o Education Department transport (school bus service) is required because access to other transport is limited.
o Education Department transport (school bus service) is preferable, but not essential.
o No Education Department transport is required.
SUMMARY:
CASE HISTORY
Please note: Your own case history form or a case history within your assessment report may be attached as long as the following details are addressed within the form and the information is current:
FAMILY DETAILS (e.g. current family status, custody/guardianship, living arrangements, siblings).
PARENT’S/CAREGIVER’S ATTITUDE TO REFERRAL: ______
FAMILY HISTORY OF SPEECH, LANGUAGE, LEARNING DIFFICULTY AND/OR DEVELOPMENTAL DELAY
RELEVANT MEDICAL & CASE HISTORY
1. Birth History
2. Motor Development/milestones (gross and fine motor)
Sat Crawled Walked
Other comments:
3. Speech and Language Development/milestones
First words at: ______Word Combinations at: ______
Other comments:
4. Hearing (eg date last assessed, results, history of middle ear infection, grommets etc)
5. Vision (eg date last assessed, results)
6. Medical Conditions, Operations etc
7. Toilet Training
8. Other
Information on children from culturally & linguistically diverse backgrounds
Does this child come from a culturally and linguistically diverse background?
Yes → Please complete the Questionnaire in Appendix 1
No → Do not complete Appendix 1
Child is of Aboriginal or Torres Strait Islander background: (Tick if applicable)
CELF-PRESCHOOL 2 (YOUNGER THAN 6 YEARS) OR CELF-4 or CELF-5 (OLDER THAN 6 YEARS)
Please complete all relevant subtests in order to obtain receptive and expressive language scores.
D.O.A.:_____/_____/______Age at Ax: ______;______
CELF P2 / R.S. / S.S. / Percentile RankSentence Structure
Word Structure
Expressive Vocabulary
Concepts and Following Directions
Recalling Sentences
Basic Concepts
Word Classes – Receptive
Word Classes - Expressive
CORE LANGUAGE SCORE
RECEPTIVE LANGUAGE SCORE
EXPRESSIVE LANGUAGE SCORE
D.O.A.:_____/_____/______Age at Ax: ______;______
CELF4 / R.S. / S.S. / Percentile RankConcepts and Following Directions
Word Structure
Recalling Sentences
Formulated Sentences
Word Classes – Receptive
Word Classes – Expressive
Sentence Structure
CORE LANGUAGE SCORE
RECEPTIVE LANGUAGE SCORE
EXPRESSIVE LANGUAGE SCORE
D.O.A.:_____/_____/______Age at Ax: ______;______
CELF5 / R.S. / S.S. / Percentile RankSentence Comprehension
Word Structure
Word Classes
Following Directions
Formulated Sentences
Recalling Sentences
CORE LANGUAGE SCORE
RECEPTIVE LANGUAGE SCORE
EXPRESSIVE LANGUAGE SCORE
RENFREW ACTION PICTURE TEST
This is a compulsory component of the referral
Please provide the child’s responses to the stimulus pictures in the Renfrew Action Picture Test (RAPT)
Scoring of this test is optional.
1.______2.______3.______4.______5.______6.______7.______8.______9.______10.______
PHONOLOGICAL AWARENESS
Clinician and/or parental reports are appropriate
WELL DEVELOPED / EMERGING / NOT EMERGING / NOT ASSESSEDSegmenting syllables
Identifying rhyme
Generating rhyme
Identifying initial sounds
Identifying final sounds
Please comment on the child’s knowledge of letter-sound correspondence.
______
FLUENCY AND VOICE
Does the child have a history of stuttering or voice issues?
oYes oNo
If yes, please comment
______
NARRATIVE
Renfrew Bus Story: Please administer according to test instructions. Scoring of this test is optional.
COMPREHENSION
Using The Bus Story say: “Let’s look at the story again.”
Ask the following questions and record the child’s response in the space provided.
Please note any prompts by writing a P.
Score the child’s original response to the question (i.e. not the prompted response).
Please rate the responses:
3 = Fully Adequate 2 = Adequate 1 = Ambiguous 0 = Inadequate
LEVELSPG / QUESTION / INSTRUCTION / I / II / III / IV
1. / Who was fixing the bus?
Why do you think the bus ran away?
What could the driver do now?
2. / What’s that? (point to train)
How are the bus and train different?
How are the bus and train the same?
Point to the train and then the policeman.
3. / Finish this: The bus jumped over the ...
Find the cow.
What is a cow?
How can we tell the bus is having a good time?
4. / What’s happening here? (point to bus going into pond)
How did the bus get out?
What do you think the bus driver said to the bus?
Where will the driver take the bus now?
Tell me something you can drive but not a bus.
TOTAL RAW SCORE (dividing by the bottom number will give the average score). / ____
3 / ____
4 / ____
5 / ____
4
AVERAGE SCORE
SPEECH
Does the child present with: o CAS o Phonological disorder o Delayed phonology
Please rate both severity and intelligibility
Severity rating: AND Intelligibility rating:
o Severe o Mostly unintelligible
o Moderate o Mostly intelligible at 1-2 word level if context is known
o Mild o Mostly intelligible at discourse level if context is known
o Age appropriate/resolving o Intelligible at discourse level whether or not context is known
Please comment on phonological processes if evident (and attach any raw data if available):
Was accessing speech pathology services a priority for the family/carer’s? oYes oNo
If yes, please list intervention focus and comment on degree of improvement:
Has the child used an alternative or augmentative communication system?
oYes currently oYes previously oNo
Please specify communication system and provide details:
THERAPY TO DATE
Number of sessions / Number ofblocks / Goals of Therapy
Individual
Group
Other
Therapy attendance: o regular o inconsistent o poor Progress: o good o moderate o limited
Please comment about the child’s progress in therapy:
Clinician signature______Date ______
EXTRA OPTIONAL INFORMATION
We encourage referring clinicians to complete the following checklist and make any additional comments.
Does the child have difficulty with joint attention?
oYes oVariable oNo
Does the child have difficulty maintaining appropriate eye contact?
oYes oVariable oNo
Does the child have flat affect or display a mismatch between words/feelings and facial expression?
oYes oVariable oNo
Is the child’s play repetitive or rote?
oYes oVariable oNo
The child’s communication style is:
oPassive oActive oDominating oNon-communicative oOther ______
If the child’s conversation is restricted to a particular topic? o Yes oSometimes oNo
If yes, please state the topic:
Is the child aware of comprehension breakdown?
oYes oVariable oNo
If yes, what strategies are evident?
oRequests for repetition oNon-verbal signs oOther
Does the child display word finding difficulties?
oYes oVariable oNo
Does the child use jargon?
oYes oVariable oNo
If possible, please comment on the child’s attention and social skills:
EXTRA OPTIONAL INFORMATION
LANGUAGE SAMPLE:
For some children with language impairment standardised assessment measures alone are not sufficient in representing their difficulties in a conversational language context. In cases when a child’s functional language performance is lower than what their language indexes on the CELF-P2 or CELF-4 suggest, or when a child performs exceptionally low on the CELF, it is recommended that referring clinicians provide a representative language sample.
Please provide a representative language sample which follows the child’s lead and reflects the child’s typical performance.
· The language sample should contain a minimum of 25 of the child’s utterances.
· Also include the context of the interaction and conversational partner’s utterances making note of any non-verbals eg. Gestures and any contextual support provided.
· If the child is largely non-verbal please make comments regarding their communicative intent.
Clinicians may include a description of observations in place of a full transcription when completing a language sample.
Year 1 Language Development Centre/School Speech Pathology Report – Application for 2018 - 2 -