Speech-Language Screening Permission

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Beyond Speech is offering pediatric speech and/or language screenings.. Please complete this form if you would like your child to be screened. If you have any questions about the screening, please call (810) 221-1663 or email jana@beyond-speech.org. You will receive screening results that indicate how your child is functioning within age-expected norms. It may also include recommendations for either a full evaluation, monitoring for 6 months, or a referral to another professional.

Thank you,

Jana Weisbrod M.S., CCC-SLP

Email *

Do you have concerns related to your child development in any of the following areas:
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Speech and language (general communication, speaking, listening, following directions, etc.)

Play and/or social skills

Literacy (i.e., learning the alphabet, rhyming, colors, shapes, etc.)

Other:

Required

I would like my child to be screened in areas related to the following concerns (you can choose more than one)
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Articulation: Speech sounds (e.g., saying “yewo” for “yellow”, “tat” for “cat”)

Expressive Language: Speaking language (e.g., not using language like other kids their age)

Receptive Language: Understanding language (e.g., not following simple directions like “Go sit down.”)

Pragmatics: Using social rules of language (e.g., not saying “hi” and “bye”, invading others’ space)

Required

Please describe any specific concerns you have for your child's speech and language (i.e., my child is not talking in sentences, they cannot pronounce the sound(s) /k,g/, etc.)
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County of residence *

Child's Name

First and last name

Child's date of birth *