Speech-Language Referral Form

Teacher Completing Referral(Required)
Student being referred(Required)

Articulation (phonology): Production of speech sounds

Substitutions – wake for take, tea for sea, yeg for leg(Required)
Omissions – moke for smoke, ca- for cat, da-y for daddy(Required)
Other: distorted sounds, "baby talk," "slushy"(Required)
Difficult to understand what they are saying(Required)

Language: Grammar (syntax/morphology): Word order in sentences, prefixes and suffixes

Deletion of word endings for plurals, verb tenses, possessives(Required)
Omission of words such as conjunctions, prepositions, "helping" verbs(Required)
Short or incomplete sentences(Required)
Incorrect pronouns such as "her" for "she" or "him" for "his"(Required)
Incorrect word order(Required)

Language: Vocabulary (semantics): Vocabulary, concepts, meaning

Incorrect word choice(Required)
Does not make sense when talking(Required)
Has trouble understanding what is said or following directions(Required)
Gives "off-the-wall" answers to questions(Required)

Language: Functional use of language (pragmatics): Rules of conversation

"Talks in circles"(Required)
Can't ask questions, describe, tell stories, or give directions(Required)
Does not interact well with other students(Required)
Talks without communicating(Required)

Voice: Voice quality, pitch, loudness

Talks "through their nose"(Required)
Breathy, hoarse, or harsh(Required)
Unpleasant voice to listen to(Required)
Too loud or too quiet(Required)
Too high or low pitched(Required)

Stuttering: Fluency or flow of speech

Gets "stuck" or repeats sounds, syllables, or words(Required)
Prolongs sound(Required)
Has extra behaviors such as facial grimaces, eye blinking, or vocal sounds(Required)