Speech & Language Screening
Please fully complete the form. For more information visit http://www.communicatingkids.net or email alison@communicatingkids.net with any questions.
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Email *
I give permission for my child to participate in a speech and language screening with Communicating Kids Speech & Language, PLLC. I understand that my typed name below becomes my legal signature.

Parent Name (First and Last)
Child’s Name (First and Last) *
Child's Birthdate *
Home Address *
Phone number *
What is the primary language in the home? What other languages are spoken in the home? *
Do you have any concerns regarding your child's speech and language skills? If yes, please explain. *
Has your child had any injuries or illnesses that may have affected speech, language and/or hearing development? Is there a family history of speech and language impairment? If yes, please explain. *
Does your child have a history of ear infections? Has your child had ear tubes inserted? If yes, to any please explain. *
Has your child previously had a speech & language and/or screening? If yes, what were the results. *
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