MyChart -

Speech-Language Pathology Services

Fax: 613-738-4853

Phone: 613-737-7600 ext. 6256

Please note that School and School Board resources and supports available to the student must be accessed prior to making a referral to School Based Rehabilitation Services (SBRS). For additional information about the SBRS program, please visit School-based Rehabilitation Services - CHEO

All fields marked with a * are required.

Student Information

Legal Last Name

Legal First Name

Gender

Address Line 1

Address Line 2

City

Postal Code

Date of Birth (dd/mm/yyyy)

Health Card Number

Version Code

Expiry date

Known diagnoses

Parent/ Guardian Contact Information (1)

Name

Relationship

Address

Same as studentOther

Address if different than student

Home #

Cell #

Work #

Please select your preferred phone number

HomeCellWork

Language

EnglishFrenchOther

If you selected other, please specify

Interpreter required?

YesNo

By providing the parent/guardian email, they are aware that it authorizes CHEO to communicate with them via email about the SBRS program. Email will not be used for urgent or sensitive communication

Parent/ Guardian Contact Information (2)

Name

Relationship

Address

Same as studentOther

Address if different than the student

Home #

Cell #

Work #

Please select your preferred phone number

HomeCellWork

Language

EnglishFrenchOther

If you selected other, please specify

Interpreter required?

YesNo

By providing the parent/guardian email, they are aware that it authorizes CHEO to communicate with them via email about the SBRS program. Email will not be used for urgent or sensitive communication

School Information

School

Public SchoolPrivate SchoolHomeschool

Student Grade

School Board

School name

School Phone Number

School Fax

If other, please specify

Primary school contact

The school is required to be actively involved in supporting the student while they are in the SBRS program. Therapists will provide recommendations for the school to implement. Please check off who will be the most responsible individual/ primary school contact for the therapist and provide their name.

If other, please specify

Name and Designation

Phone and Email

Secondary school contact (optional)

If other, please specify

Name and Designation

Phone and Email

Attestation

If the referral is for a student in Grade 7 or above: The Referral Source attests that they have spoken to the student who is being referred, and the student is agreeable to the SBRS referral and will be receptive to the recommendations

Please select one of the following

YesNoN/A

Consent

I, the referral source, have obtained student/parental/legal guardian consent to complete this referral for CHEO's SBRS program. I have reviewed with the student/parent/legal guardian that the information collected, used, and disclosed will be used to arrange necessary services as part of the student's treatment at school, and that this consent can be withdrawn at any time

Date

Referral source name (person completing this form)

Signature

Speech Language Pathology Services

Articulation and Phonological Difficulties

A1 Subjective Clinical Impression of Severity

Mild (NOT ELIGIBLE): 1 to 2 sound errors OR no phonological processes OR errors within developmental range OR lateral/frontal lisp on /s,z/ only OR sound patterns with that of L1 OR /r/ to [w]Moderate: 3 sound errors OR phonological processesModerate-severe: 4-6 sound errors OR phonological processes (including atypical errors)Severe: More than 6 sound errors OR processes involved (including atypical errors)

Motor Speech Difficulties

A2 Subjective Clinical Impression of Severity

Mild: Less than 3 errors and errors are inconsistent over repeated trialsModerate: 3 to 6 errors and errors are inconsistent over repeated trialsSevere: More than 6 errors and errors are inconsistent over repeated trialsProfound: Efforts to speak/vocalize, limited sound system

Fluency Difficulties

A3 Subjective Clinical Impression of Severity

Voice/ Resonance Difficulties

Report from ENT or Cleft Palate team required within 6 months of referral

Check if the referral is related to

Voice

Resonance

N/A

Report from ENT or Cleft Palate team completed

Yes

A4 Subjective Clinical Impression of Severity

Mild: Vocal production or resonance impacts communications in 1-2 daily or regular activitiesModerate: Vocal productions or resonance impacts communication in 3 or more dailty or regular activitiesSevere: Vocal productions or resonance are markedly affected OR majority of communication may require non-verbal techniques

Sections B-E are to be completed for ALL referrals

B - Speech Intelligibility

Good: Sometimes not understood in conversationFair: Frequently not understood in conversationPoor: Mostly or completely not understood in conversation

C - Social Impact

D - Emotional Impact

Low: Child does not seem to be experiencing apparent emotional impact of speech difficultiesModerate: Child appears to be experiencing some emotional impact of speech difficulties (eg. tears, anger, frustration, temper tantrums) 3 or less times a weekHigh: Child appears to be experiencing significant emotional and/or behavioural impact of speech impairment (eg. outbursts, physical aggression) 4 or more times a week - daily

E - Academic Impact

Low: Not applicable OR Speech difficulties is not impacting child's academic achievementModerate: Speech difficulties seems to be impacting child's academic achievement in 1-2 subjects (eg. difficulty writing or reading, but still able to understand written message)High: Speech difficulties seem to be significantly impacting child's academic achievement in most subjects (eg. unable to understand written message or express written idea)

Additional Comments

Note: An SLP report is required within the last 12 months of referral. Please fax all applicable reports and supporting documents to 613-738-4853.

CHEO School Based Rehabilitation Services (SBRS) Referral Form