speech pathology referral report 20language...

Year

SPEECH PATHOLOGY REFERRAL REPORT 2020 LANGUAGE DEVELOPMENT CENTRE

PLACEMENT YEAR ONE STUDENT DETAILS: NAME: __________________________________________ DOB:____________ GENDER Male Female CHRONOLOGICAL AGE AT TIME OF ASSESSMENT:___ CURRENT SCHOOL:__________________________ IS THE CHILD AN AUSTRALIAN CITIZEN OR PERMANENT RESIDENT: ________________________________ ADDRESS: ___________________________________________________________________________________ POST CODE:__________________________________ TELEPHONE NUMBER: __________________________ MONTH AND YEAR OF FIRST EVER S.P. CONTACT:______ DATE OF LDC REFERRAL:___________________ PREVIOUS THERAPY: None – assessment only Minimal contact/Indirect contact Regular intervention

REFERRING AGENCIES: Who has initiated the referral? (please tick) Parent Speech Pathologist Teacher School Psychologist Other

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 t rue and correct. I wish this application for placement at the _________________________________________________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

Specify

Year 1 Language Development Centre/School Speech Pathology Report – Application for 2020 - 1 -

initiator:[email protected];wfState:distributed;wfType:email;workflowId:0ec7e874b0cfa64699b5503ccbc3e98f

In order to assist the processing of referrals, please complete the following questions. DOES THE CHILD HAVE:

OTHER AGENCIES INVOLVED (if known):

TRANSPORT REQUIREMENTS•This information is to help inform school planning only. •Transport information provided does not define or limit families' transport options upon enrolment.•Please note that students attending full time LDC placements (i.e. Pre-primary, Years One and Two students) are prioritised for seats on the bus over those attending part-time placements (i.e. Kindergarten students).

Education Department transport (school bus service) is required because access to other transport is limited. Education Department transport (school bus service) is preferable, but not essential.

No Education Department transport is required.


1. An intellectual disability?2. Severe epilepsy?3. Autism or Asperger’s Syndrome?4. Global Developmental Delay?

Paediatrician / Medical Officer - Contact Name: ________________________________________________________

Developmental assessment completed and copy attached

Occupational Therapist - Contact Name: _________________________________________________________

Physiotherapist - Contact Name: ___________________________________________________________________

Disability Services Commission (DSC) - Contact Name: _________________________________________________

National Disability Insurance Agency (NDIA) - Contact Name: ____________________________________________

Autism Association - Contact Name: ________________________________________________________________

The Ability Centre (formerly Centre for Cerebral Palsy) - Contact Name: _____________________________________

School of Special Educational Needs Sensory (SSENS) - Contact Name:____________________________________

Other(s) - Contact Name: ________________________________________________________________________

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 (eg 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/milestonesFirst 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-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 Rank Sentence 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: ______;______

Year 1 Language Development Centre/School Speech Pathology Report – Application for 2020

CELF5 R.S. S.S. Percentile Rank Sentence ComprehensionWord 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

Segmenting syllables

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?

________________________________________________________________________________________________

If yes, please comment:

Identifying rhyme

Generating rhyme

Identifying initial sounds

Identifying final sounds

Comments (optional)

Notes:


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

LEVELS PG 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

AVERAGE SCORE

Comments:

SPEECH

Does the child present with: CAS Phonological disorder Delayed phonology

Please rate both severity and intelligibility

Severity rating: AND Intelligibility rating:

Please comment on phonological processes if evident (and attach any raw data if available): ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

THERAPY TO DATE

Was accessing speech pathology services a priority for the family/carer’s? If yes, please list intervention focus and comment on degree of improvement: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Has the child used an alternative or augmentative communication system? Please specify communication system and provide details: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________



Number of sessions

Number of blocks Goals of Therapy

Individual

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ __________________________________________________________ __________________________________________________________

Group

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ __________________________________________________________ __________________________________________________________

Other

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ __________________________________________________________ __________________________________________________________

Therapy attendance: Progress:

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?

Does the child have difficulty maintaining appropriate eye contact?

Does the child have flat affect or display a mismatch between words/feelings and facial expression?

Is the child’s play repetitive or rote?

The child’s communication style is:

If the child’s conversation is restricted to a particular topic?

If yes, please state the topic: _____________________________________________________________

Is the child aware of comprehension breakdown?

If yes, what strategies are evident?

Does the child display word finding difficulties?

Does the child use jargon?

If possible, please comment on the child’s attention and social skills: ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________

Requests for repetition Non-verbal signs Other



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 t he 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.

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ADDITIONAL COMMENTS

_____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________

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