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Speech and Language Milestone Survey
Please answer the following questions below. Based on your answers, Ashley Reed, M.S., CCC-SLP will contact you directly with speech and language recommendations for your child.
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Guardian's Name
*
Your answer
Email
*
Your answer
Phone Number
*
Your answer
Child's Name
*
Your answer
How old is your child?
*
Under 1
1
2
3
4
5
6
Older than 6
What areas of concern do you have for your child?
*
My child is not speaking like other children his/her age
My child is unable to produce specific sounds
My child has difficulties comprehending language
My child has difficulties with social skills
My child is stuttering
Required
If concerned about specific sounds, what sounds does your child struggle with based on the picture below. (If not applicable, answer N/A)
Your answer
If concerned about language, what areas does your child struggle with based on the picture below. (If not applicable, answer N/A)
*
Your answer
Additional information you would like to include:
*
Your answer
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