Speech-Language Referral Form Teacher Completing Referral(Required) Teacher First Name Teacher Last Name Email for Copy of Submission(Required) Campus(Required)LakesidePlantTildenStudent being referred(Required) Student First Name Student Last Name Student's Grade Level(Required)PK3PK4K5123456789101112Articulation (phonology): Production of speech soundsSubstitutions – wake for take, tea for sea, yeg for leg(Required) Yes No Omissions – moke for smoke, ca- for cat, da-y for daddy(Required) Yes No Other: distorted sounds, "baby talk," "slushy"(Required) Yes No Difficult to understand what they are saying(Required) Yes No Language: Grammar (syntax/morphology): Word order in sentences, prefixes and suffixesDeletion of word endings for plurals, verb tenses, possessives(Required) Yes No Omission of words such as conjunctions, prepositions, "helping" verbs(Required) Yes No Short or incomplete sentences(Required) Yes No Incorrect pronouns such as "her" for "she" or "him" for "his"(Required) Yes No Incorrect word order(Required) Yes No Language: Vocabulary (semantics): Vocabulary, concepts, meaningIncorrect word choice(Required) Yes No Does not make sense when talking(Required) Yes No Has trouble understanding what is said or following directions(Required) Yes No Gives "off-the-wall" answers to questions(Required) Yes No Language: Functional use of language (pragmatics): Rules of conversation"Talks in circles"(Required) Yes No Interrupts(Required) Yes No Can't ask questions, describe, tell stories, or give directions(Required) Yes No Does not interact well with other students(Required) Yes No Talks without communicating(Required) Yes No Voice: Voice quality, pitch, loudnessTalks "through their nose"(Required) Yes No Breathy, hoarse, or harsh(Required) Yes No Unpleasant voice to listen to(Required) Yes No Too loud or too quiet(Required) Yes No Too high or low pitched(Required) Yes No Stuttering: Fluency or flow of speechGets "stuck" or repeats sounds, syllables, or words(Required) Yes No Prolongs sound(Required) Yes No Has extra behaviors such as facial grimaces, eye blinking, or vocal sounds(Required) Yes No Other Comments: