Monitoring and referral procedures

Monitoring communication checklist

Child's name: _______________________

Date of birth: __________________

Date of enrolment: __________________________

Date: ________________

Name of centre: ____________________________________________________

Staff member completing form: _________________________________________

Concern raised with regard to:

Voice (Y/N) ____
Stuttering (Y/N) ____
Language (Y/N) ____
Speech Sounds (Y/N) ____

Concern raised by: ________________________________________
Centre staff
Parent/caregiver
Other

Briefly describe concern:
________________________________________________________

________________________________________________________

________________________________________________________

Action taken:
________________________________________________________

________________________________________________________

________________________________________________________

Speech sample taken (attach)
Handout given to parent
Communication Observation completed (attach)
Referred for hearing assessment
Language Sample taken (attach)
Other

Plan:
________________________________________________________

________________________________________________________

________________________________________________________

Monitor for ____ weeks/months

Review date

Diaried

No further Action

Refer to GSE

Planned strategies to help during monitoring period:
________________________________________________________

________________________________________________________

________________________________________________________

Outcome of review:
________________________________________________________

________________________________________________________

________________________________________________________

Signed by (staff member): _____________________________

(Parent): ______________________________

Date: _______________________