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RTI Referral Process

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kishacharles
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57 views6 pages

RTI Referral Process

Uploaded by

kishacharles
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Speech Therapy RTI/Referral Information

Student Name ___________________ Grade ___________ DOB __________


Student ID # ______________________ Teacher Name ___________________________
1. Did student pass hearing & vision screenings? YES NO

2. Is more than one language spoken in the home? YES NO


a. If yes, what language(s)? _____________________________

3. Teacher concerns (check all that apply):


___ I can’t understand the words my student uses
___ My student doesn’t speak enough
___ My student stutters
___ My student doesn’t seem to understand me
___ My student has poor language and/or vocabulary skills

4. Write examples of what your student says (use back, if needed):

5. Have you noticed any academic impact related to your concerns?


___ Spelling/writing errors
___ Errors impact ability to express academic knowledge
___ Errors impact oral reading fluency
___ Other ___________________________________________________

6. Have you noticed any social/emotional impact related to your concerns?


___ Student misarticulations distract from their message
___ Student is aware of errors
___ Student is embarrassed by errors
___ Student is frustrated by errors
___ Peers tease student about speech
___ Negative social stigma because student sounds less mature
___ Student is reluctant to participate in class
___ Other _____________________________________________________

7. Do parents have concerns? YES NO


a. Date of parent contact ____________________
b. List parent concerns (use back, if needed):

©KI Speech, LLC


RTI Meeting Plan

Student _________________________________ Student ID ___________________


Parent __________________________________ Phone # _____________________

Teacher ________________________________________

Date of Meeting ____________________________________________________

Plan:
___ Referral initiated

___ RTI for ____ weeks


___ Developmentally Appropriate

___ Rescreen: Date _______________________

Summary of RTI Goals:


______________________________________________________________________________

______________________________________________________________________________
______________________________________________________________________________

______________________________________________________________________________
______________________________________________________________________________

______________________________________________________________________________

Additional Notes:
______________________________________________________________________________

______________________________________________________________________________
______________________________________________________________________________

______________________________________________________________________________

©KI Speech, LLC


Language Screening Checklist

Student __________________________________ Teacher ________________________


Date _________________________

Please check all skills your student has/is able to do.


F=Frequently, S=Sometimes, R=Rarely

Skill F S R
Initiates verbal interactions with others
Responds appropriately when classmates attempt to initiate
interaction
Uses words to express emotions/feelings
Participates in class discussions
Responds appropriately when asked a question
Asks questions that are relevant to situation
Asks for help when needed
Uses appropriate sentence structure for age/grade
Follows one step directions
Follows 2 step directions
Follows multi-step directions
Answers yes and no questions
Answers who, what, where, when questions
Answers why questions
Uses vocabulary comparable to peers
Answers questions about stories read aloud to him/her
Uses pronouns he, she, they correctly
Uses plural –s correctly
Uses –ing verbs correctly
Uses appropriate subject-verb agreement
Understands basic concepts: in front, behind, on, under, next to
Understands basic concepts: more, less, many, few, some, all
Can tell a simple story
Uses is/are correctly in sentences
Uses descriptive words with nouns (big bear, small dog, etc.)
Uses irregular plural nouns
Uses irregular past tense verbs
Can identify items that go together
Can identify items based on function (i.e. What do we use to
write?)

©KI Speech, LLC


Articulation Quick Screener Record Form

Student __________________________________ Teacher ________________________

Date _________________________

Target Word Correct Target Word Correct


Sound +/- Sound +/-
P pie P map
B bunny B web
T two T bat
D dice D bed
M mouse M comb
N net N fan
W white
K cup K book
G go G wagon
F four F leaf
V vase V cave
S sun S bus
Z zoo Z rose
L lock L balloon
S-blend spider S-blend stop
L-blend block L-blend plate
SH shoe SH fish
CH cheese CH peach
J juice J bridge
R ring R paper
TH thumb TH bath
©KI Speech, LLC
Articulation Quick Screener Word List
©KI Speech, LLC
Articulation Quick Screener Word List
©KI Speech, LLC

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