Speech & Language Screening

Guardian Information *

First Name

Last Name

Phone *

(###)

###

####

Child's Information *

First Name

Last Name

Areas of Concern *

Check all that apply

Speech sounds (unclear words, difficult to understand)

Language (using words, putting sentences together)

Social communication (playing, interacting, turn-taking)

Fluency (stuttering, repeating sounds/words)

Voice (hoarse, nasal, or unusual voice quality)

Feeding/swallowing concerns

General developmental concerns

Not sure, just want a screening

Consent *

I understand this is a screening only and does not replace a full evaluation or therapy.

Yes