Algonquin And Lakeshore Catholic District School Speech And Language Referral Form
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LGONQUIN AND
AKESHORE
ATHOLIC
ISTRICT
CHOOL
OARD
151 Dairy Avenue, Napanee, Ontario K7R 4B2
Telephone: (613) 354-2255
Fax: (613) 354-9850
1-800-581-1116
The information gathered on this form is collected pursuant to the Education Act and the Municipal Freedom of Information and Protection of Privacy Act.
Information will be used to prepare assessment records; maintain records for students. User: Student Services Staff, Principal of student, all Teachers
responsible for the student’s program and designated staff for clerical functions.
SPEECH AND LANGUAGE REFERRAL FORM
NAME:
D.O.B.:
TEACHER:
YY/ MM/ DD
SCHOOL:
GRADE:
Kindergarten Group
A / B
PARENT(S) NAMES:
ADDRESS:
POSTAL CODE:
TELEPHONE NUMBER: (Home):
(Work):
AREAS of CONCERN
(Check all areas that best describe student’s difficulty)
ARTICULATION: Speech is hard to understand:
occasionally
often
most of the time
LANGUAGE:
Vocabulary:
Uses gestures in place of language (e.g., pointing)
Uses vague terms in place of simple vocabulary (e.g., that, there)
Grammar:
Immature sentence structure
Comprehension / Listening:
Difficulty understanding directions
Difficulty listening to / understanding stories
Limited attention, easily distracted
Social Use of Language (Pragmatics):
Difficulty using language to interact with peers
Associated behaviour problems
Difficulty with conversational rules (e.g., turn taking)
Difficulty retelling a story/past event
Unusual social behaviours (e.g., poor eye contact)
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