Parent Information

Liberty Hill Elementary “Building Strong Educational Foundations” Local Support Team Information Packet for Speech Dear Parent, Your child has been recommended by his or her teacher and the Liberty Hill Elementary Local Support Team as a candidate for the Speech and Language Response to Intervention Program. Your child will be monitored during the program to track his or her progress. He or she will participate in speech and/or language activities aimed at improving articulation and/or language skills. The following packet includes information for you about the Local Support Team (LST) and the Response to Intervention (RTI) process for speech. Please contact your child’s teacher or Lisa Woodruff, Liberty Hill Elementary Speech Pathologist at 515-6514 if you have any questions or concerns. Please fill out this permission form and information packet and return it with your child at your earliest convenience. Thank you for your support. Sincerely, Lisa Woodruff, M.S., CCC-SLP Local Support Team Liberty Hill Elementary I give permission for my child ___________________________, to be screened and/or to attend the Speech and Language Response to Intervention Program at Liberty Hill Elementary if so recommended. _________________________________ Signature of Parent or Guardian ________________ Date Liberty Hill ISD Local Support Team Information Packet for Speech/Language Parent Information Student Name: __________________________________ Teacher Name: __________________________________ Date of Birth: ____________________________ Grade: _________________________________ Person Completing this Form: _______________________________ Relation to student: ________________ Please answer YES or NO to the following questions. If you answer YES, please describe. 1) Has your child had ear infections? YES NO Describe __________________________________ 2) Does your child have any health concerns (including allergies)? YES NO Describe __________________________________ 3) Has your child been referred for further testing for hearing or vision? YES NO Describe __________________________________ 4) Did your child experience any serious injuries or illnesses? YES NO Describe __________________________________ 5) Are there any other languages spoken in the home? YES NO Describe __________________________________ 6) Has your child ever been in a speech therapy program? YES NO Describe __________________________________ 7) Is there a family history of speech, language, or learning problems? YES NO Describe __________________________________ Please list your child’s strengths and weaknesses. Strengths Weaknesses Please list your child’s interests/hobbies _________________________________________________________ How does your child respond to correction for language, behavior, or speech errors? _____________________ __________________________________________________________________________________________ Liberty Hill ISD Local Support Team Information Packet for Speech/Language Communication Skills Information Please describe your child’s skills using the following scale: 1- No Problem 2- Minimal Problems Noted                Met speech/language milestones Produces speech sounds correctly in words Speaks fluently without repetition/hesitation Imitates/repeats information Expresses needs/wants Expresses ideas/thoughts Uses multiple word sentences (4+ words) Uses correct grammar/sentence structure Uses vocabulary similar to same age peers Gains attention from parents/siblings/peers Seeks help or clarification when needed Uses facial expression/body language to communicate Participates appropriately in conversation Relates an event or story in order Follows 1-2 step directions 3- Significant Problems Noted 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 Please add any information that you feel is important for the Local Support Team (LST) to know about your child _____________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Thank you for your time in filling out these forms. Please let us know if we can help you in any way. If you have any questions regarding the Response to Intervention (RTI) process for Speech that has been recommended for your child, please contact your child’s teacher and/or Lisa Woodruff, Liberty Hill Elementary Speech Pathologist at 515-6514. Liberty Hill ISD Local Support Team Information Packet for Speech/Language Student Name: _____________________________ Person Completing Form: __________________________ Parent Articulation Observations Please listen to your child in conversation and indicate which sounds you hear that he or she pronounces correctly (+) or mispronounces (-). Please circle the word indicating if the sound is mispronounced in the beginning, middle, or end of the word. Sound /p/ as in pig, apple, cup /b/ a in baby, web /t/ as in toy, water, bat /d/ as in doll, middle, bed /k/ as in king, pocket, rake /g/ as in goat, buggy, tag /m/ as in mad, hammer, thumb /n/ as in name, funny, fan /ng/ as in finger, ring /r/ as in run, carrot, /er/ as in early, nurse, fur /l/ as in lion, pillow, tall /h/ as in hat, anyhow + - Sound /f/ as in food, coffee, off /v/ as in vote, oven, stove /s/ as in sock, missing, ice /z/ as in zoo, fuzzy, fuzz /sh/ as in shoe, wishing, fish /zh/ as in pleasure /ch/ as in chair, watching, pitch /dg/ as in judge, engine, garage /th/ (soft) as in thing, healthy, tooth /th/ (hard) as in those, brother, bathe /w/ as in way, anyway /y/ as in yellow, canyon Total Number of Missed Sounds + - 1) Do you feel that the sound errors you noted are typical for children who are your child’s age? YES NO 2) Do you feel that your child is aware of his or her sound errors? YES NO 3) Does your child become frustrated when attention is drawn to his or her sound errors? YES NO 4) Please list 15 words that your child has difficulty pronouncing: 1 6 11 2 7 12 3 8 13 4 9 14 5 10 15 Adapted from Allan K. Bird, Ph.D. Liberty Hill ISD Local Support Team Information Packet for Speech/Language