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South Bend Community School Corporation

Special Education Services

Referral for Multidisciplinary Team Evaluation – Speech Impairment

Classroom Teacher’s Report

Please check:

_____Parent referral (attach Record of Parental Request)

_____Teacher referral (date referred_____________)

Classroom Teacher completes these pages:

Student: _______________________ School: _________________ ID#: ___________ STN#: _______________

Teacher providing information: ____________________ How long has student been in your class? ____________

Subject area(s) if applicable: _____________________________________________________ Grade: _________

Students may present difficulties in their speaking that could indicate the presence of a speech disorder or

impairment in the areas of fluency, articulation, and/or voice. Please check in the area(s) below any

suspected significant difficulties this student is having in the classroom and other settings in the school

environment.

Fluency

A fluency disorder may also be described as “stuttering. Many young children demonstrate some of the below

behaviors but usually “grow out of it”. Disfluency is an interruption in the flow of speaking typically characterized by

excessive:

_____repeating of part-words, whole-words, phrases

_____prolonging of sounds, ____ syllables

_____interjecting sound/syllables, whole words, phrases

_____pausing at the beginning of words, sentences, and in the middle of sentences _____breaking within words

Other behaviors:

_____abnormal breathing pattern (gasping for breath, audible inhaling, etc.)

_____speaking rate unusually fast, slow, abnormally fluctuating

_____struggling to speak as evidenced by eye blinks, tightening lips, wrinkling nose, forehead, etc, tongue clicking,

etc.

_____using gestures excessively

_____does not ____does (if does - ___minimally ____significantly) seem to impact academic and social functioning

in classroom and other school settings

Comments:__________________________________________________________________________________

___________________________________________________________________________________________

Articulation

A student’s speech may contain some sound “differences” that could include sounds that have not yet matured

(e.g. w/r for a 5 year old), are characteristic of a dialectical difference (e.g., ah/ai as in fine), and/or actual sound

errors (e.g., t/k for a 5-6 year old).

_____substitutes one or several sounds for other(s)

_____omits sound(s) from words

_____adds additional sound(s)

_____distorts sound(s)

_____student’s speech is ____mildly ____moderately _____severely unintelligible

8/19/12

Referral For Multidisciplinary Team Evaluation - Speech Impairment Classroom Teacher'S Report