Support Coordinator Speech Pathology referral form - Down South Therapy

Support Coordinator referral form for Speech Pathology

Speech Pathology supports children in developing their communication skills, including speech clarity, language understanding, and social interactions. If you have concerns about a participant’s ability to express themselves, follow instructions, or engage with others, this form is designed to capture those observations. By providing information here, you help our team determine how we can best assist your student in improving their communication abilities, enhancing their confidence and interaction with peers.
Please note, you will be required to include contact details a participant's caregiver before submitting this form (Name, Phone, and Email). You will also be asked to confirm that consent has been obtained for this referral. Please ensure you have this information prior to completing the form.

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Referral Information

Participant Name(Required)

First Last

Date of birth(Required)

MM slash DD slash YYYY

Class

Current School

Support Coordinator's Name(Required)

First Last

Support Coordinator's Email(Required)

Important Notice Gmail account holders: If you use a Gmail account, you will not receive a notification upon submission. However, rest assured that our team will still receive your referral successfully.

Support Coordinator's Phone

The following concerns relate to Speech Pathology

This checklist aims to provide information about the concerns of the support coordinator and/or family regarding the participant’s communication skills. It assists the speech pathologist to provide a targeted speech/language and/or literacy assessment tailored to the participant’s needs. Please mark (tick) the appropriate box if you have concerns for the areas below. A space is left below for any additional comments. Please note that this is a general referral form used for all ages and as such the participant may not be at the developmentally appropriate age expected for completing stated task. Please tick the relevant statements below regarding the reasons for referring this participant.

Articulation (Speech Sounds)

Listeners have difficulty understanding the participant’s speech.

Difficulties with producing 1 or more speech sounds (/p/, /b/, /t/, /d/, /n/, /m/, /w/,/h/, /s/, /f/, /k/, /g/, /sh/, /l/, /r/, blends /sp/, /st/ etc. and /th/)

Receptive Language (Comprehension and understanding)

Difficulty understanding concepts. For example, size concepts such as “big” and “little”, “long” and “short”, or descriptive concepts such as “soft” and “hard”.

Difficulty understanding prepositions such as “in” , “on”, “under”, “behind”, “between”, “next to”.

Difficulty following instructions with 2 or more steps, such as “Get your drink bottle and line up”.

Difficulty answering “what”, “where”, “who”, “when” and “why” questions.

Expressive Language (Grammar and Vocabulary; Retelling stories)

Leaves out words or uses telegraphic or abbreviated sentences. For example, “He patting cat” rather than “He is patting the cat”.

Makes errors with pronouns. For example, uses “him” instead of “he”, “he” instead of “she”, or “me” instead of “I”.

Makes errors with verb tense, such as “ing” and “ed” word endings being left off or incorrectly added. For example, “I rided my bike”.

Mixes up the order of words in sentences. For example, “I like lollie blue”.

Uses very few connector words such as “and” and “because”. Leaves them out or uses incorrect words. For example, “The boy go up the ladder. He need to get the cat” instead of “The boy is going up the ladder because he needs to get the cat”.

Has a limited vocabulary and may overuse nonspecific words such as “this”, “that”,

“thing” or “stuff” and/or may present with word finding or naming difficulties.

Difficulties telling stories, retelling events or sharing news. May lack important details, be out of sequence or confusing.

Literacy (Phonological awareness, Reading, Spelling, Written expression)

Difficulty with identifying letters and sounds

Difficulty with identifying beginning and end sounds of spoken words

Difficulty with segmenting and blending sounds in words

Makes spelling errors not expected for year of schooling and despite having received phonics instruction

Does not apply sounding out skills to reading and spelling tasks

Difficulties with using punctuation in writing despite receiving classroom instruction.

Difficulties with structuring of writing into sentences (year 1-2) and/or paragraphs (year 4 and above).

Social Thinking and Social Skills

Difficulty with initiating conversations, asking questions or taking turns in conversation

Speaks on one topic at length despite disinterest from others

Poor use of eye contact

Unexpected body proximity or leaving a group or room without explanation or appropriate farewell

Stuttering

Stuttering such as word or sound repetitions (“I I wa want to…”) , prolongations (“Mmmmister”) or blocking before onset of word observed.

Voice

Husky, croaky or hoarse voice observed. Also recommend GP referral to ENT (Ear, Nose and Throat specialist.

Comments: Please feel free to write any other information about your concerns below

How we use this information

The information you provide in this form is confidential and used solely to evaluate the child’s needs and determine suitability for therapy services. Thank you for choosing Down South Therapy, we look forward to working together to make a positive impact.

Consent(Required)

Please complete the following information to confirm you have discussed these concerns with the parent/caregiver and have consent to submit this referral.

Please check this box to confirm that you have discussed these concerns and recommendations with the parent/caregiver of this participant

Please check this box to confirm that you have obtained consent from the participant’s parent/caregiver to submit this referral.

Please check this box to confirm that you have informed the parent/caregiver that Down South Therapy will contact them upon receiving this referral.

Caregiver's Name(Required)

First Last

Caregiver's Email(Required)

Caregiver's Contact Number(Required)

Name

This field is for validation purposes and should be left unchanged.

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Support Coordinator referral form for Speech Pathology

Referral Information

The following concerns relate to Speech Pathology

How we use this information

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