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. We accept payment via PayPal or personal check (see below for specific payment details). Payment is due by Wednesday, February 6, 2019.

These speech-language screenings will take place over many days/weeks, depending on how many students sign up. We will notify you via e-mail of the intended date for your child, but we will need to be flexible to accommodate each child's special classes.

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 at jen@cslclinic.com or 847-821-1237 ext. 202

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 school during the school day, or at our Long Grove office location.

I understand and I authorize Central Speech & Language Clinic to perform a speech-language screening for my child.

I do not want my child to participate in this screening.

Child's Last Name: *

Your answer

Child's First Name: *

Your answer

Birthdate: *

YYYY

Child's Room Number: *

Your answer

Teacher's Name: *

Your answer

Full Name of Person Filling Out this Form: *

Your answer

Relationship to Child: *

Mother

Father

Legal Guardian

Address: *

Your answer

City: *

Your answer

Zipcode: *

Your answer

Phone Number: *

Your answer

E-mail: *

Your answer

I will submit $25.00 and my payment will be in the form of: *

Note: Checks should have child's name in the memo and be made out to Central Speech & Language Clinic.

Personal Check - Mailed to Central Speech & Language Clinic, 4160 IL Route 83, Suite 304, Long Grove, IL, 60047

Personal Check - Dropped off in Parkview's Office

PayPal Payment - Go to www.paypal.com. Send payment to: payments@cslclinic.com. Click on "Send Money". Click on purchasing "Services". Enter $25.00 as the amount. Write "Screening Payment" in the subject line and your child's name in the message portion of the e-mail at the bottom of the payment screen.

Please choose all that apply regarding your child's language use: *

My child speaks English and English is primarily spoken at home.

My child is multi-lingual.

My child understands better in one language than the other(s).

My child understands about the same amount in all languages.

My child speaks in one language better than the other(s).

My child speaks using all languages equally well.

I have speech and language concerns in only one of the languages.

I have speech and language concerns across all languages.

Other:

Required

If your child is multi-lingual, please describe his/her use of each language and/or any concerns you may have.

Your answer

Please check all that apply regarding your child's articulation skills. *

mispronounces those sounds that are typically pronounced correctly by peers

says single words clearly but is difficult to understand in conversation

deletes parts of words (ie. says “ca” for “cat”)

deletes syllables in words (i.e. says “boon” for “balloon”)

No Concerns

Other:

Required

Please check all that apply regarding your child's oral motor skills. *

sensitive gag reflex

messy eater

avoids certain foods

drools (at rest or while eating)

swallowing difficulties

coughing while eating or drinking

No Concerns

Other:

Required

Please check all that apply regarding your child's fluency. *

stutters on individual sounds or syllables (i.e. “t-t-table” or “ta-ta-table”)

repeats whole words or phrases

stutters in most environments (i.e. playground, classroom, home, etc.)

has “blocks” so that no sound is coming out but effort is being made to talk

uses excessive filler words (i.e. “um,” “like,” and “you know”)

No Concerns

Other:

Required

Please check all that apply regarding your child's expressive language skills. *

has trouble expressing wants and needs

repeats or echoes what others have said without apparent understanding

has difficulty forming and/or answering questions

has difficulty generating sentences

No Concerns

Other:

Required

Please check all that apply regarding your child's receptive language skills. *

has difficulty following the daily routine

has difficulty understanding/ remembering/ following verbal directions

looks around the room to see what others are doing when given oral directions

lacks an understanding of basic concepts ( i.e. “on,” “first,” “empty,” etc.)

No Concerns

Other:

Required

Please check all that apply to your child's vocabulary skills. *

has a weak expressive vocabulary (uses vague words, such as “that thing”)

understands under 25 words

understands 25-75 words

understands over 75 words

uses / expresses under 25 words

uses / expresses 25-75 words

uses / expresses over 75 words

No Concerns

Other:

Required

Please check all that apply regarding your child's pragmatic / social language use. *

has difficulty initiating and/or maintaining a conversation

has difficulty with eye contact

lacks ability to interpret body language (i.e. gestures, facial expressions, etc.)

demonstrates difficulty with turn-taking

demonstrates lack of interest in engaging with other children

No Concerns

Other:

Required

Please check all that apply regarding your child's early literacy skills. *

has difficulty rhyming

has trouble learning the alphabet and numbers

has difficulty separating sounds in words or blending sounds to make words

has difficulty recognizing their written name

Not applicable due to child's age

No Concerns

Other:

Required

Is there a family history of speech-language-reading disorders? *

Yes. If yes, please explain below (in the "other" box)

Other:

Please let us know if you have any other concerns that you feel we should know about.

Your answer

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