118 – 11th Street E.

Prince Albert, SK S6V 1A1

PH: (306) 953-7500 Fax: (306) 763-1723

Email: info@pacsd.ca

SPEECH & COMMUNICATION REFERRAL FORM

Name:

Date of Birth:

Parents/Guardians:

Age:

Address:

Grade:

Postal Code:

Repeated Grade:

Phone Contact #:

School:

Teacher:

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Please check the areas in which you notice the student is having difficulty:

· articulation

· language (vocabulary, grammar, etc.)

· hearing: Please circle: frequently asks you to repeat things, middle ear tubes,

history of middle ear infections

auditory processing (understanding verbal instructions or questions, memory

difficulties, disorganization, word-retrieval difficulties)

· attention

· stuttering

· voice (hoarse, nasal)

· pragmatics (social communication)

Other:

· received Early Childhood Services prior to school entrance:

Please circle: SLP, OT, PT, Other: _________________

· seen an Educational Psychologist Evaluation

· academic challenges

· behavior problems

· EAL (English as an Additional Language) – First Language is _________________

Additional Comments/ Information:

_____________________________________________________________________

_________ ____________________________________________________________

NOTE: Signed Individual Evaluation Consent Form must accompany this referral form.

____________________________________________________Referral SourceDate

Revised: June 2015