Note: to Be Completed for EACH Student for Whom Funding Is Requested for 2017

State Support Services 2017

Request to Access Services

Note: To be completed for EACH student for whom funding is requested for 2017

School Name:Campus:

Family Name:First Name:

Date of Birth:Gender:Male / FemaleYear Level 2017

Service Requested

Applications must be supported by a report from the visiting teacher or speech pathologist. Please attach Visiting Teacher Report or Speech Pathologist Report.

Type of Service / Service
Requested

Visiting Teacher of Physical/Health Impaired
Visiting Teacher of Hearing Impaired
Visiting Teacher of Vision Impaired
Speech Therapy

History

Where was the student enrolled in Term 1, 2016?

Did this student receive funding from State Support Services in 2016? Yes No

From whom was the service purchased:

Rationale for Program

Describe how the provision of these services will contribute to the educational opportunities and experience of the student and assist in meeting the educational needs described in the eligibility criteria.

Endorsement of Parent/Guardian:

Name of Parent or Guardian:

Signature: Date:

Please note that a statement by an assessing professional does not automatically guarantee additional funding.

Privacy Notice: Independent Schools Victoria protects the privacy of students, along with the confidentiality and security of personal information provided, in compliance with the Privacy Act 1988, the Health Records Act 2001 and other relevant Acts. Independent Schools Victoria collects personal information when a school applies for additional resources to support a student. This information is collected to enable Independent Schools Victoria to determine the level of additional resources to be provided to the school after eligibility has been established. Independent Schools Victoria collects student information only from the school. A copy of all documentation is held by the school. The information provided is used primarily to assess the educational resourcing and services required by the student. Information may be used by Independent Schools Victoria in conjunction with other educational bodies for research and analysis purposes, with the aim of improving resourcing and services for students with disabilities. In such cases the information will be de-identified except with the written consent of the parents and the school. It is not disclosed to anyone else without the written consent of the parents. There may be some occasions when Independent Schools Victoria is required by law to disclose information about a student. In most circumstances, Independent Schools Victoria will let the parents know, wherever possible in advance, if it is required to do this. All information provided to Independent Schools Victoria about a student is kept secure and treated as confidential.

State Support Services 2017

Speech Pathology Service

Speech Pathologist Assessment Report: Language Impairment

School Name:Campus:

Family Name:First Name:

Date of Birth:

Year Level 2017: Prep□ Year 1 □ Year 2□Year 3 □Year 4 □

Section A:

Language Background

Does the student have a Language Background other than English?YesNo

(If no, go to next section)

Was the student born in Australia?YesNo

If not, when did the student arrive in Australia?

How long has the student been educated in English (only include one year of preschool education) ______

Describe how long and in what contexts the student has been exposed to English?

Languages spoken at home by family members

L1 Language Use – What is student’s L1? (the first language the child is exposed to) ______

______

Describe the current performance in L1

History of L1 development and use

Use of L1 within the home

Difficulties in L1 (reported and observed)

You can use parent report, interpreter (not peers) and speech pathology evidence. This can be derived in informal and in structured situations. Take care in using tests to assess a non-English language. This can only be descriptive as norms do not apply

L2 Language Use – What is student’s L2? (Subsequent language exposed to)

Describe the current performance in L2

History of L2 development and use

Use of L2 within the home

Section B

Assessments: All scores must be completed

Test Used / Date
Assessed / Receptive/ Listening / Expressive/
Speaking / Total/
Core Score

Assessment Results

Comment on the assessment results. What implications do the results have for the student’s learning? Is there evidence of a languageimpairment in the student's first language?

Section C

Therapy Plan: A New Therapy Plan for 2017 is required

Outline the plan for speech therapy for this student including goals and strategies. Indicate how service will be delivered: direct intervention, consultation, monitoring. Attach further documentation if necessary.

Where funding has been provided in previous years, document progress in therapy:

Evaluation

How will the speech therapy program be evaluated?

Section D

Professional Statement

Is it your professional opinion that this student has a moderate to severe language impairment?

□Yes□No

Comment:

Name:Position:

Organisation: Signature:

Date:

State Support Services 2017

Speech Pathology Service

Speech Pathologist Assessment Report: Voice / Fluency Disorder

School Name:Campus:

Family Name:First Name:

Date of Birth:Year Level 2017:

Application for / 
Moderate to severe voice disorder
Moderate to severe fluency disorder
Alternative or augmentative non-speech communication system
such as communication board, signing or an electronic device

Assessments

Standardised assessments should be administered and the results reported. The report should address details of the student’s problems such as percentage of syllables stuttered and specific voice problems.Include copies of original assessment proformas.

Assessment Tool / Date Assessed / Results

Comment on the assessment results. What implications do the results have for the student’s learning?

Student Name:School/Campus:

Therapy Plan: A New Therapy Plan for 2017 is required

Where funding has been provided in previous years, document progress in therapy:

Evaluation

How will the speech therapy program be evaluated?

Professional Statement

Is it your professional opinion that this student has a moderate to severe voice or fluency disorder, or is in need of an alternative or augmentative communication system?□Yes □No

Comment:

Name:Position:

Organisation: Signature:

Date:

State Support Services 2017

Speech Pathology Service

Speech Pathologist Assessment Report: Speech Sound Disorder

School Name:Campus:

Family Name:First Name:

Date of Birth:Year Level 2017:

Assessments

Standardised assessments should be administered and the results reported. The report should address details of the student’s problems such as developmentally and clinically significant errors, including sounds in error and level of intelligibility.

Assessment Tool / Date Assessed / Results

Comment on the assessment results.

Sound errors in isolation:

Stimulability of sounds in error:

Error pattern at single-word level:

Error pattern at conversational level:

Consistency of errors at single-word level:

Consistency of errors at conversational level:

Phonological processes evident: (provide evidence of full range of sounds affected)

Intelligibility: (including percentage of consonants)

Therapy Plan: A New Therapy Plan for 2017 is required

Where funding has been provided in previous years, document progress in therapy:

Evaluation

How will the speech therapy program be evaluated?

Professional Statement

Is it your professional opinion that this student has a moderate to severe speech sound disorder □Yes □No

Comment:

Name:Position:

Organisation: Signature:

Date: