Students with Disabilities Program 2016
Form 3: Severe Language Disorder
Form to assist confirmation of eligibility to be completed by a registered psychologist.
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 registered psychologist within the SWD 2016 guidelines to provide evidence that the student
does not have social-emotional and/or cognitive factors that significantly contribute to the presenting
language difficulties.
Section One
School Name:
Location:
E No:
E
Student Surname:
Student First Name:
Date of Birth:
2016 Year Level:
Section Two
Psychologist’s Name:
Title
First Name
Surname
Name of Agency:
Date of Assessment:
Telephone:
Facsimile:
Form 3: Severe Language Disorder (Registered Psychologist)
Email Address:
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RESULTS
IQ SCORE
PERCENTILE RANKING
IQ SCORE
PERCENTILE RANKING
WPPSI – IV
Date Tested:
Verbal Comprehension Index
Visual Spatial Index
Fluid Reasoning Index
Working Memory Index
Processing Speed Index
Full Scale IQ
Nonverbal Ancillary
WISC- IV
RESULTS
Date Tested:
Verbal Comprehension Index
STANFORD BINET
Perceptual Reasoning Index
5th Ed
Date Tested:
WAIS- IV
Date Tested:
Working Memory Index
Processing Speed Index
Full Scale IQ
Comments regarding cognitive factors:
Does the student present with social-emotional factors which require comment? No
Yes
If yes, please detail evidence regarding these social-emotional factors and provide evidence ruling out these as
a variable contributing significantly to the presenting severe language disorder.
Signed:
Form 3: Severe Language Disorder (Registered Psychologist)
Date:
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