Central Speech & Language Clinic - Speech & Language Screenings (Parkview Montessori)
Central Speech & Language Clinic will be providing speech and language screenings at your child's school.  If you would like your child to participate, please fill out this form and provide payment in the amount of $25.00 by Friday, January 12th.   CSLC accepts online payment at:  paypal.me/cslclinic

Each screening will be conducted by a licensed and certified speech-language pathologist.  She will assess your child's speech (articulation / speech sound production), receptive language (understanding of language), expressive language (ability to express needs and thoughts), fluency (stuttering), and voice.  

If you have any questions regarding this process, please contact Jen Malone Priest, MA CCC-SLP, Clinic Director.  Email: jen@cslclinic.com or call/text:  847-821-1237

Sign in to Google to save your progress. Learn more
I understand that this is only a screening, an abbreviated assessment, which will indicate; (1) my child appears to be performing appropriately for his or her age group, or (2) my child would benefit from a more in-depth evaluation. *
After the screening, I will receive a written summary of the results.  The results of the screening will also be shared with the staff at the school.  If further testing is recommended, I will be provided with information including multiple options for proceeding.  There is no obligation to use CSLC's services, however, CSLC is available to provide services at Parkview Montessori during the school day, or at our Long Grove office location.  
Child's Last Name: *
Child's First Name: *
Birthdate: *
MM
/
DD
/
YYYY
Child's Room Number: *
Teacher's Name: *
Full Name of Person Filling Out this Form: *
Relationship to Child: *
Address: *
City: *
Zipcode: *
Phone Number: *
Please choose all that apply regarding your child's language use: *
Required
If your child is multi-lingual, please describe his/her use of each language and/or any concerns you may have.
Please check all that apply regarding your child's articulation skills. *
Required
Please check all that apply regarding your child's oral motor skills. *
Required
Please check all that apply regarding your child's fluency. *
Required
Please check all that apply regarding your child's expressive language skills. *
Required
Please check all that apply regarding your child's receptive language skills. *
Required
Please check all that apply to your child's vocabulary skills. *
Required
Please check all that apply regarding your child's pragmatic / social language use. *
Required
Please check all that apply regarding your child's early literacy skills. *
Required
Please mark all that apply regarding your child's health history:
Is there a family history of speech-language-reading disorders? *
Please let us know if you have any other concerns that you feel we should know about.
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Central Speech and Language Clinic.

Does this form look suspicious? Report