Central Speech & Language Clinic - Speech & Language Screenings (Parkview Montessori)

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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

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.

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: *

Child's First Name: *

Birthdate: *

YYYY

Child's Room Number: *

Teacher's Name: *

Full Name of Person Filling Out this Form: *

Relationship to Child: *

Mother

Father

Legal Guardian

Address: *

City: *

Zipcode: *

Phone Number: *

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.

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”)

Peers do not seem to understand my child's speech

Unfamiliar listeners do not seem to understand my child's speech

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.)

does not consistently respond to name

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

Please mark all that apply regarding your child's health history:

My child has allergies

My child has asthma

My child breathes through his/her mouth during the day

My child breathes through his/her mouth while sleeping

My child snores while sleeping

My child wakes frequently at night or has difficulty sleeping

My child has enlarged tonsils

My child has enlarged adenoids

My child has/had frequent ear infections

My child has hearing loss

My child wears glasses

My child has eating/feeding/swallowing difficulties

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.

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