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Speech Therapy Referral Guidelines

​Warning Signs that should trigger a referral to an SLP at any age:

  • Shows decline in ability to be understood by family, friends, and/or caregivers in the expression of basic needs, preferences, and feelings

  • Speech is usually slurred; difficulty controlling respiration for speech; abnormal loudness, rhythm, or vocal quality

  • Produces no meaningful words or sounds that are understood only by family

  • Speaks loudly in high pitched voice with frequent distortion, omission, and substitution of sounds

  • Exhibits difficulty learning sounds to form words; may sound nasal, strangled and/or breathy

  • Sound errors are prevalent but variable (i.e., "dog" could be produced "dog," "tog," "gog," "god" by same child)

  • Varies from rarely being able to produce sounds to ongoing speech that is rarely understood, or speech that is usually understood with frequent sound errors

  • Unaware of sound variations or exhibits varying degrees of frustration and/or anxiety regarding inability to "control speech"

  • Cannot produce movements for sound production or sounds are produced without voice (whispered speech)

  • Exhibits frustration and/or avoidance of speech due to difficulties


Age-specific Warning Signs

By 6 months:

  • Does not laugh or squeal

  • Does not look toward new sounds


By 9 months:

  • Has limited or no babbling

  • Does not indicate when upset


By 12 months:

  • Does not point to objects

  • Does not use gestures such as waving or shaking head


By 15 months:

  • Has not used first word

  • Does not respond to “no” and “bye-bye” appropriately


By 18 months:

  • Does not use at least six to ten words consistently

  • Does not hear well or discriminate between sounds


By 20 months:

  • Does not use at least six consonant sounds (especially /p, b, m, n, w, h/)

  • Does not follow simple directions


By 24 months (2 years):

  • Has a vocabulary of less than 50 words

  • Has decreased interest in social interactions compared with previously


By 3 years:

  • Cannot be understood by family and/or caregivers more than 50% of the time

  • Cannot correctly produce vowels and the consonants /p, b, m, w/ in words

  • Cannot repeat when not understood without getting frustrated


By 4 years:

  • Cannot be understood by family/strangers more than 75% of the time

  • Cannot correctly produce /t, d, k, g, f /

  • Cannot be asked to repeat without becoming sensitive


By 5 years:

  • Cannot be understood in all situations by most listeners

  • Cannot correctly produce most speech sounds

  • Cannot be asked to repeat without exhibiting frustration





*Information courtesy of the American Speech-Language Hearing Association (ASHA) and the Linguisystems Milestones Development Guide (Flahive and Lanza, 2012)

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