Child's Full Name
Please describe your child's communication difficulties:
Has your child previously received treatment?
If yes when and where:
Is your child aware or frustrated/anxious about these difficulties?
How does your child prefer to communicate?
Please share an example of a typical sentence said by your child.
What is the total number of words your child has in their vocabulary?
Less than 10 words
Uses 2-word combinations (i.e. Daddy go)
Uses 3-word combinations (i.e. Mommy go out)
Uses 4-6 word sentences (i.e. My dog's name is Annie.)
Speaks in full sentences
Typical for children his/her age
Please Identify those behaviors your child demonstrates consistently
repeats sounds, words or phrases over and over
difficulty answering questions
difficulty understanding what you are sayng
difficult to understand
plays alone for unreasonable lengths of time
poor eye contact
easily frustrated / impulsive
easily distracted / short attention
separation difficulties or anxiety
Please list any speech errors your child may use (i.e. says /w/ for /r/, can't say /th/)
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