Students with Disabilities Program 2016
Form 2: Severe Language Disorder
Form to assist confirmation of eligibility to be completed by a speech pathologist.
A diagnosis of severe language disorder is determined by a speech pathologist (who is eligible for membership
in Speech Pathology Australia) (Form 2) and a registered psychologist (Form 3). Nominated students must be
assessed by a speech pathologist within the SWD 2016 guidelines to provide evidence that the student does
not have; hearing or English as an Additional Language/Dialect and cultural factors that significantly contribute
to the presenting language difficulties.
Please tick the box if this is a Severe Developmental Verbal Dyspraxia application
 Please attach a comprehensive diagnostic report written by a speech pathologist with attention
given to the impact of dyspraxia on intelligibility of speech and literacy development. Refer to SWD
2016 Guidelines (page 12).
Section One
School Name:
Location:
E No:
E
Student Surname:
Student First
Name:
2016 Year
Level:
Date of Birth:
Section Two
Speech Pathologist’s
Name:
Title
First Name
Surname
Name of Agency:
Date of Assessment:
Telephone:
TEST INFORMATION
Facsimile:
TESTS ADMINISTERED
Email
Address:
SCORES
Receptive Language
Expressive Language
As a qualified speech pathologist completing this assessment:

I believe that the above scores are an accurate representation of the student’s oral language abilities and
where CELF-4 or CELF-Preschool 2 scores have been reported, these are based on Australian normative
data.
Form 2: Severe Language Disorder (Speech Pathologist)
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Please outline any additional comments related to this oral language assessment:
Does the student have a history of hearing impairment?
No
Yes
If YES, please detail evidence ruling out this variable as contributing significantly to the
presenting severe specific oral language impairment.
Does the student have a history of English as an Additional Language/Dialect (EAL/D)?
No
Yes
If YES, please detail evidence ruling out this variable as contributing significantly to the presenting severe
specific oral language impairment.

The following factors need to be considered when providing evidence that results cannot be accounted
for by a hearing loss and/or by non-English speaking background or cultural factors:
- The length of exposure to English and language use in the home environment.
- Did the student experience significant language delay when in a monolingual environment?
- The results from dynamic assessment processes (monitoring of progress following targeted teaching
sessions).
- The student’s Basic Interpersonal Communication Skills (BICS) versus Cognitive Academic Language
Proficiency (CALP). It is expected that in the normal English as an additional language/dialect (EAL/D)
population it takes 5 – 9 years for CALP to progress to the same level as English only speaking peers,
whereas BICS usually develops within 2 years (Cummins, 2008).
 Please note that the speech pathologist should provide a statement that outlines clearly the speech
pathologist’s belief about the nature of the impact of EAL/D on the student’s presentation of Severe
Language Disorder.
 Please note that assessment in a student’s first language is only appropriate where formal
assessment tools designed and normed in that language are used and the student has only limited
exposure to English. If you are assessing a student in their first language it is deemed inappropriate
to use a translated version of an English assessment tool such as those listed in the LNSLN guidelines.
(Bedore & Peña 2008)
The statement should provide evidence and clarity as to the speech pathologist’s belief about the
nature of the impact of English as an Additional Language/Dialect (EAL/D) on his/her presentation with
a Severe Language Disorder.
Signed:
Form 2: Severe Language Disorder (Speech Pathologist)
Date:
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