Speech & Language Screener
Fill out this form, and our team of speech-language pathologists will review to determine if further follow-up is recommended. Thank you!
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Child's First and Last Name: *
Person filling out form (first and last name) and relationship to child: *
Phone number to contact for follow up: *
Child's birthdate:
How many ear infections has your child had?

RECEPTIVE LANGUAGE:

Does your child follow simple directions (e.g., “Get your shoes”)?

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Can your child point to common objects or pictures when named?

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Does your child understand and respond to basic questions (e.g., “Where’s your toy?”)?

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Can your child follow multi-step directions (e.g., “Put the book on the table and get your cup”)?

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EXPRESSIVE LANGUAGE:

How many different words does your child use?
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Can your child combine two or more words into phrases (e.g., “Want cookie”)?

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Does your child use sentences with four or more words?

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Can your child tell a short story or describe an event in sequence? 

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SPEECH SOUND PRODUCTION: 

What percentage of your child's speech do you understand?
What percentage of your child's speech do you think an unfamiliar listener would understand?
Check the sounds your child CANNOT produce, or can only produce in certain contexts:
Is there anything else you would like us to know about your child?
Which provider, if any, sent you this form? This helps us know where to direct the results.
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