Liberty Hill Elementary

“Building Strong Educational Foundations”

Local Support Team Information Packet for Speech

Dear Parent,

Your child has been recommended by his or her teacher and the Liberty Hill Elementary Local Support Team as a candidate for the Speech and Language Response to Intervention Program.

Your child will be monitored during the program to track his or her progress. He or she will participate in speech and/or language activities aimed at improving articulation and/or language skills.

The following packet includes information for you about the Local Support Team (LST) and the Response to Intervention (RTI) process for speech. Please contact your child’s teacher or Lisa Woodruff, Liberty Hill Elementary Speech Pathologist at 515-6514 if you have any questions or concerns.

Please fill out this permission form and information packet and return it with your child at your earliest convenience. Thank you for your support.

Sincerely,

Lisa Woodruff, M.S., CCC-SLP

Local Support Team

Liberty Hill Elementary

I give permission for my child ______, to be screened and/or to attend the Speech and Language Response to Intervention Program at Liberty Hill Elementary if so recommended.

______

Signature of Parent or Guardian Date

Parent Information

Student Name: ______Date of Birth: ______

Teacher Name: ______Grade: ______

Person Completing this Form: ______Relation to student: ______

Please answer YES or NO to the following questions. If you answer YES, please describe.

1)Has your child had ear infections?

YESNODescribe ______

2)Does your child have any health concerns (including allergies)?

YESNODescribe ______

3)Has your child been referred for further testing for hearing or vision?

YESNODescribe ______

4)Did your child experience any serious injuries or illnesses?

YESNODescribe ______

5)Are there any other languages spoken in the home?

YESNODescribe ______

6)Has your child ever been in a speech therapy program?

YESNODescribe ______

7)Is there a family history of speech, language, or learning problems?

YESNODescribe ______

Please list your child’s strengths and weaknesses.

Strengths / Weaknesses

Please list your child’s interests/hobbies ______

How does your child respond to correction for language, behavior, or speech errors?______

______

Communication Skills Information

Please describe your child’s skills using the following scale:

1- No Problem2- Minimal Problems Noted3- Significant Problems Noted

  • Met speech/language milestones123
  • Produces speech sounds correctly in words123
  • Speaks fluently without repetition/hesitation123
  • Imitates/repeats information123
  • Expresses needs/wants123
  • Expresses ideas/thoughts123
  • Uses multiple word sentences (4+ words)123
  • Uses correct grammar/sentence structure123
  • Uses vocabulary similar to same age peers123
  • Gains attention from parents/siblings/peers123
  • Seeks help or clarification when needed123
  • Uses facial expression/body language to communicate123
  • Participates appropriately in conversation123
  • Relates an event or story in order123
  • Follows 1-2 step directions123

Please add any information that you feel is important for the Local Support Team (LST) to know about your child ______

______

______

Thank you for your time in filling out these forms. Please let us know if we can help you in any way. If you have any questions regarding the Response to Intervention (RTI) process for Speech that has been recommended for your child, please contact your child’s teacher and/or Lisa Woodruff, Liberty Hill Elementary Speech Pathologist at 515-6514.

Student Name: ______Person Completing Form: ______

Parent Articulation Observations

Please listen to your child in conversation and indicate which sounds you hear that he or she pronounces correctly (+) or mispronounces (-). Please circle the word indicating if the sound is mispronounced in the beginning, middle, or end of the word.

Sound / + / - / Sound / + / -
/p/ as in pig, apple, cup / /f/ as in food, coffee, off
/b/ a in baby, web / /v/ as in vote, oven, stove
/t/ as in toy, water, bat / /s/ as in sock, missing, ice
/d/ as in doll, middle, bed / /z/ as in zoo, fuzzy, fuzz
/k/ as in king, pocket, rake / /sh/ as in shoe, wishing, fish
/g/ as in goat, buggy, tag / /zh/ as in pleasure
/m/ as in mad, hammer, thumb / /ch/ as in chair, watching, pitch
/n/ as in name, funny, fan / /dg/ as in judge, engine, garage
/ng/ as in finger, ring / /th/ (soft) as in thing, healthy, tooth
/r/ as in run, carrot, / /th/ (hard) as in those, brother, bathe
/er/ as in early, nurse, fur / /w/ as in way, anyway
/l/ as in lion, pillow, tall / /y/ as in yellow, canyon
/h/ as in hat, anyhow / Total Number of Missed Sounds

1) Do you feel that the sound errors you noted are typical for children who are your child’s age?

YESNO

2) Do you feel that your child is aware of his or her sound errors?

YESNO

3) Does your child become frustrated when attention is drawn to his or her sound errors?

YESNO

4) Please list 15 words that your child has difficulty pronouncing:

1 / 2 / 3 / 4 / 5
6 / 7 / 8 / 9 / 10
11 / 12 / 13 / 14 / 15

Adapted from Allan K. Bird, Ph.D.

Liberty Hill ISD

Local Support Team Information Packet for Speech/Language