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Kindergarten Language Development Centre/School Speech Pathology Report – Application for 2020 - 1 -
SPEECH PATHOLOGY REFERRAL REPORT 2020 LANGUAGE DEVELOPMENT CENTRE
PLACEMENT KINDERGARTEN
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 Other
REFERRING SPEECH PATHOLOGIST: PAEDIATRICIAN/ MEDICAL OFFICER /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 true 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
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) areprioritised 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.
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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:
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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)
Kindergarten Language Development Centre/School Speech Pathology Report – Application for 2020 - 4 -
CELF-PRESCHOOL 2 Please complete all relevant subtests in order to obtain receptive and expressive language scores and attach all raw data. D.O.A.:_____/_____/_________ Age at Ax: ______;______
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
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. _________________________________________________________________________________________
FLUENCY AND VOICE Does the child have a history of stuttering or voice issues? If yes, please comment:
_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Notes:
Kindergarten Language Development Centre/School Speech Pathology Report – Application for 2020 - 5 -
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: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Kindergarten Language Development Centre/School Speech Pathology Report – Application for 2020 - 6 -
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: ________________________________
Kindergarten Language Development Centre/School Speech Pathology Report – Application for 2020 - 7 -
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
Kindergarten Language Development Centre/School Speech Pathology Report – Application for 2020 - 8 -
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-5 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.
____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________
Kindergarten Language Development Centre/School Speech Pathology Report – Application for 2020 - 9-
ADDITIONAL COMMENTS
____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________
Kindergarten Language Development Centre/School Speech Pathology Report – Application for 2020 - 10 -
![HISTORY OF SPEECH-LANGUAGE PATHOLOGY [Autosaved]](https://img.dokumen.tips/doc/110x75/5886a5bd1a28ab0c1d8b70c1/history-of-speech-language-pathology-autosaved.jpg)
