SPEECH AND LANGUAGE THERAPY SERVICEAIREDALE NHS FOUNDATION TRUST

SCHOOL AGE REFERRAL CHECKLIST

NAME OF CHILD ...... DOB ......

Please fill in the appropriate sections and give examples of the child’s difficulties.

Listening and Understanding

For example

Does he understand as his peers, does he/she wait and follow his peers when given a classroom instruction, does he respond to key words but often misses the more complex or subtle language? Is he not coping with language of learning - conceptual language?

Your examples

Using Language

For example

Cannot sequence telling a story or an event. Frequent ‘tip of the tongue’ phenomena eg unable to recall words previously known. Is very rigid in his language use or does not respond appropriately to questions

Your examples

Using Speech Sounds

For example

Has difficulty with some speech sounds. Reduces multisyllabic words. Is unintelligible to most people most of the time.

Your examples

Social Communication

For example

Shows unexpected responses to questions. Is not aware of the use of register ie an awareness to speak to teachers differently to peer group.

Your examples

Stammering

For example

Repeats sounds or words. Prolongs sounds eg ‘fffffish’. Gets stuck or pushes out the sound or word.

Changes or avoids some words. Uses a starter phrase.

Your examples

Voice Quality

For example

Voice is persistently hoarse even when he does not have a cold or regularly loses voice. Speech sounds very nasal. Voice sounds too high/low

Your examples

LEVELS OF CONCERN

This may be useful in gauging whether the difficulty is perceived in the same way by both parent and referrer.

It may help where there is a significant discrepancy between a parent and a referrer and when you may need to discuss further before the parent is happy for the child to be referred.

What is the level of professionals concern?1______5______10

What is the level of child’s/student’s concern?1______5______10

What is the level of parental concern?1______5______10

How is this communication difficulty impacting on his/her progress and well being?

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How concerned are you about the child’s communication difficulties?

LITTLE CONCERNVERY CONCERNED

PARENT

I feel this will develop without intervention - I would like some advice - I would like an assessment and possibly therapy

1 510

REFERRER

DelayedMonitorMonitor and AdviceRefer

1 510

SALT\New Shared Docs\Paediatric\Admin\Referrals\School Age Referral Checklist (2014)