Speech & Language Pre-Screening Questionnaire

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Child's First & Last Name *

Child's Date of Birth *

YYYY

Contact Information

Parent's Name *

Parent's Phone Number *

Parent's Email Address *

I give permission for my child to have a speech and language screening. *

Yes

Pertinent Information

Please answer the following questions about your child's speech and language development.

What percentage of the time is your child's speech understood by strangers? *

0-25%

25-50%

About 50%

50-75%

75-100%

Always 100%

Has your child suffered from chronic ear infections? *

Yes

Has had some ear infections, but has not been chronic

Did your child ever have pressure equalization tubes inserted? *

Yes

How often does your child follow verbal instructions? *

Rarely

Sometimes

Often

Always

Do you feel your child has difficulty following directions? If yes, please explain.

What is the child's primary language? *

Are other languages spoken in the home? If yes, please list the languages and the child's exposure. (Example: Dad Spanish every day, Grandma Mandarin on weekends)

Can you provide a few examples of sentences that you might hear your child say? (Examples: More water. I want cars. We went to the park yesterday.)

Please use this space to provide any pertinent history or concerns (developmental delays, other medical conditions).

Payment Information

Please provide your credit card information. Your card will not be charged until your screening is scheduled.

Name on Card *

Card Number *

Expiration Date *

Security Code *

Billing Zip Code *

I give permission for Pediatric Therapy Playhouse to charge my credit card once my screening has been scheduled. *

Yes

COVID Precautions

Prior to each session, each therapist will take the temperature of her child and any accompanying family members. Therapists take their own temperatures 2 x day. *

I understand.

All clients and family members who enter our clinic must wash hands upon arrival. *

I understand.

Masks are required for adults entering the office and recommended for children who can tolerate them. Therapists will be wearing masks. *

I understand.

Our waiting room will be closed until further notice. Each client may have one adult accompany him/her into the treatment room or wait in their car. *

I understand.

At this time, please try to limit additional family members accompanying children to sessions (one adult to accompany each child is preferred). *

I understand.

Please try to be right on time for your session (rather than being early) in order to decrease congestion in the waiting area. *

I understand.

A child may not attend in-clinic sessions if he/she, his/her family members, or anyone they have been in contact with have experienced the following symptoms in the past 14 days: Fever, cold, chills, muscle aches, sore throat, cough. *

I understand.

We do not allow families into the clinic who have attended an indoor gathering of more than 10 people in the last two weeks. *

I understand.

We do not allow child/accompanying family members to come into the clinic if they have traveled using public transportation (plane, bus, train, cruise ship) in the last 2 weeks. *

I understand

I understand and assume the liability for attending an in-clinic session. *

I understand.

Virtual Options

If you do not qualify for in-clinic visits based on the above policies, or if you/your family member/anyone in your household is medically compromised, please contact our Clinic Director, Hannah@PediatricTherapyPlayhouse.com to schedule a virtual screening.

Next Steps

Please look out for an email from us with a scheduling link and additional details!

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