Speech & Language Development Information (Child)
This form will provide information about your child's speech and language development. Content given in this form will allow TeleVine Therapy to have a better understanding about your child.
Parent/Legal Representative Name
Do you remember your child lying in their crib and making play type sounds, such as cooing and/or babbling?
Do you remember this child attempting to copy or mimic words, gestures, games (Peek-a-boo, patty-cake)?
Does anyone in the family have a hearing or speech problem? If so, what relation are they to your child?
At what age was your child when he/she said his/her first meaningful word? What was it?
At what age was your child when he/she used 2 word phrases? Please provide an example.
At what age was your child when he/she used sentences? Please provide an example.
Are there some words that this child appears to understand but cannot say, such as bye-bye, baby, no, cookie, bath, etc.? List examples below.
Check any and all statements which accurately describe this child’s present speech and language behaviors.
Follows directions well
Seems to understand what is said to him/her
Appears to have difficulty hearing
Consistently responds to his/her name or speech sounds when not facing the speakers
Needs to look at the person speaking in order to understand
Seems to be unaware of sounds in the environment (ex. telephone, TV)
Rarely attempts speech
Depends primarily on signs and gestures instead of speech
Attempts speech, but is difficult to understand
Uses speech sounds incorrectly (omits/substitutes/distorts sounds)
Stammers or stutters
Talks too fast
Talks too slow
Uses an abnormal pitch level (too high/too low)
Uses complete sentences
Uses only phrases
Uses no speech
Does your child use a spoon/fork?
If your child uses a spoon/fork, what hand do they use?
Can use both
Describe your child's eating habits and neatness.
Send me a copy of my responses.
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