Upstate Pediatric Speech Therapy Services, Inc.

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Referral for a Language Disorder

Review each item if your child does not demonstrate a particular skill at a given developmental age, then print out this and check each option that applies:

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Referral to a Speech-Language Pathologist is necessary when:

___  By AGE 1, Does not respond to music and/or singing
___  Cannot understand simple questions
___  Does not look at familiar people when named
___  Does not maintain eye contact, attention to speaker
___  Little interest in social interaction, language, or pointing
___  Does not say mama or dada
___  Does not begin to imitate words
___  Does not say 1-2 words imitatively

___  By AGE 2, cannot identify basic body parts
___  Cannot understand simple commands, like give me without gestures
___  Does not demonstrate action words (i.e., eat)
___  Does not speak using 1-2 words at a time
___  Does not use new words frequently, at least 50 words

___  By 2-1/2, Does not use short sentences
___  Does not respond to hello and bye consistently

___  By AGE 3, Does not relate experiences verbally
___  Does not state first/last name

___  By AGE 4, does not use short but grammatically correct sentences
___  Does not understand comparisons or make basic inferences

___  By AGE 5, does not use complex sentences
___  Does not explain how to do something
___  Does not respond to why questions with a reason
___  Does not understand complex directions
___  Does not understand concepts
___  School-Age Receptive Language - Exhibits difficulties understanding teachers instructions and/or following directions
___  Exhibits difficulties in reading comprehension across subjects
___  Exhibits difficulties in mathematical reasoning, learning numbers, and/or concepts and applications
___  School-Age Expressive Language - Difficulties in oral and/or written expression including appropriate
         use of words,  grammar, and underlying meaning

___  Difficulties in basic reading skills, including the ability to decode letters and words and attain information
___  Difficulty interpreting and applying abstract written information

The above items can be used as a basic screening tool to determine if your child needs services. This checklist can be brought to the evaluation as part of the case history intake information. If you checked several items in your childs category or if there are gaps in development, please contact the uPs Therapy office to schedule an evaluation at (864) 438.0990. Insurance is accepted for most companies.

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