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.
Child's Last Name: *
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Child's First Name: *
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Birthdate: *
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Child's Room Number: *
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Teacher's Name: *
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Full Name of Person Filling Out this Form: *
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Relationship to Child: *
Address: *
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City: *
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Zipcode: *
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Phone Number: *
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E-mail: *
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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.
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.
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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. *
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Please check all that apply regarding your child's expressive language skills. *
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Please check all that apply regarding your child's receptive language skills. *
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Please check all that apply to your child's vocabulary skills. *
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Please check all that apply regarding your child's pragmatic / social language use. *
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Please check all that apply regarding your child's early literacy skills. *
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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.
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