Questionnaire

Dear Parent/Caregiver,

This questionnaire will help us learn about your child's communication skills.

Please Complete the questionnaire.

Tick all behaviours that your child has previously exhibited or currently exhibits.

Please note, that we require your email to send you a copy of your answers.

We also require your name and phone number to be able to contact you to set a first appointment.

All info gathered in this form is private and only the therapist and parents would have access to it...

Thank you!

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Email *
Your Name: *
Your Phone Number: *
Your Relationship to child: *
Child's name: *
Date of Birth: *
Please use the name of the month instead of its number for less confusion.
e.g.: March 2nd 2019, or 2 March 2019
Gender: *
Does your child go to a nursery or school? *
Name of the nursery or school: *
Home Address: *

My child has:

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Required
List of Siblings Information
(Name, Age, Relationsip
e.g. Sam, 11, brother
Lilly, 8, sister...)
 *

The language(s) spoken at home to my child is/are:

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Required

The language(s) spoken in community to my child is/are:

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Required

The language(s) spoken in nursery/school to my child is/are:

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Required

How old was your child when you first noticed they were stuttering?

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Has the stuttering severity changed since it first started? How?

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What were the circumstances around the onset of stuttering? Were there any significant changes or events that happened at the time? For example, starting school, moving house, new sibling born, a traumatic event etc.

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How often do you observe your child using sound repetition: a single sound is repeated multiple times e.g. "Can I have the p p p p p pencil?"

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How often do you observe your child using syllable repetition: one syllable/part of a word is repeated multiple times e.g. "Can I have the pen. pen.pen. pen. pencil?"

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How often do you observe your child using word repetition: a whole word is repeated multiple times e.g. "Can..can..can I have the pencil?"

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How often do you observe your child using phrase repetition: two or more words in a phrase are repeated multiples times e.g. "Can I have. can I have. can I have the pencil?"

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How often do you observe your child using prolongation: a sound is stretched out and continued for an inappropriate length of time e.g. "Caaaaaaaaan I hhhhhhhhhave the pencil?"

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How often do you observe your child using blocking: a stop in airflow and the inability to get a word out as if the word is 'stuck' e.g. C--------an l have the pencil?"

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How often do you observe your child using fillers: words are added to a sentence e.g. Can I um um um um have the pencil?"

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Some children who stutter try to escape their stuttering moment by for example raising their voice to push the word out or moving head jerking. Does your child do any of the folowing while stuttering?

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Required

Some children will avoid or delay speaking because they stutter by, for example, restarting their sentence over and over to avoid saying a word they think they might stutter on. Does your child do any of the following?

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Required

On a grade from 1 to 10, how much would you say your child talks throughout the day? (1 being they don't talk a lot at all, 10 being they don't stop talking)

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How frustrated does your child get when they stutter? (1 being rarely frustrated, 10 being extremely frustrated)

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From your perspective, is the occurrence of stuttering consistent throughout the day or does it depend on (tick any/all that apply):

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Required

How do you usually react to your child when they are stuttering? Is there anything you do to help?

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How do siblings react to your child stuttering?

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How do grandparents react to your child stuttering?

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How do friends react to your child stuttering?

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How do strangers react to your child stuttering?

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My Child is mostly: (Check all the boxes that would describe your child)

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Required

Is there anything else you would like to share regarding your child's stuttering?

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Do you have any other questions or concerns regarding your child's speech or language development?

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A copy of your responses will be emailed to the address you provided.
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