Speech & Language Screening Questionnaire

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Do you think your child need speech? Please complete the following screening questionnaire for us to address your concern via phone conference.

Email *

Your name: *

Your child's age: *

The language(s) spoken to my child is/are:

English

Spanish

Other:

When at home, my child usually:

watches television

plays with adults

plays with other children

plays independently

Other:

When spending time with adults, my child often:

goes on errands (e.g., grocery shopping, taking brother or sister to sport practice)

plays physical games (e.g., peek-a-boo, tag, tossing and catching a ball)

plays learning games (e.g., names body parts, names colors, counts, names letters, puts together puzzles)

looks at books

Other:

When playing with other children, my child sometimes

plays beside other children without sharing his or her toys

plays with other children by following what they do or say

plays with other children by telling them what to do

plays with other children by sharing toys and talking

My child does not play with other children

Other:

When playing, my child:

shakes and bangs objects

plays simple games with me (e.g., peek-a-boo, pat-a-cake)

plays with toys appropriately (e.g., rolls ball, stacks blocks, makes stuffed dog walk and bark)

uses toys in pretend play (e.g., uses a straw as a sword, pretends blocks are cookies)

plays with two or more toys together (e.g., stacks two or more blocks, rolls/pushes a car into stacked blocks)

acts out familiar situations (e.g., dresses a doll, makes a doll, drive a car, pretends to eat and drink from toy plates and cups)

acts out unfamiliar situations (e.g., flies a doll to the moon, walks a stuffed animal through the jungle)

My child pays attention to what's happening around him or her. For example, my child:

reacts to sounds (e.g., startles when a door is slammed, looks up when the doorbell rings)

looks up from what he/she is doing when I call his or her name.

looks at people who are talking

looks for food that's fallen from his or her high chair

looks forward where I'm pointing when I say, "Look at the ___."

My child enjoys attention. For example, my child:

smiles when I talk to him or her

"talks" when I talk to him or her (e.g., coos, gurgles, says sounds like "ma, dada, ai-yee"

takes turns talking with me using sounds or words

invites me to play with him or her (e.g., deliberately drops a toy from the high chair to be picked up, touches me and runs to play "catch me," brings me a toy or book)

My child follows my directions when I:

use gestures (e.g., hold out my hands to pick him or her up, wave bye-bye)

say words paired with gestures (e.g., say no-no while shaking head, say look while pointing)

say words and simple phrases (e.g., stop, wait, come here, show me)

say one-part directions (e.g., get your blank, give me a kiss, eat your cracker)

say two-part directions (e.g., find your shoes and bring them here, get your blankie and lay down, get your spoon and eat your ice cream)

My child tells me how he or she feels and he or she wants. For example, my child:

uses different vocalizations to express himself or herself (e.g., has different cries, screams when angry, coos when happy, whimpers when tired)

points to things he or she wants (e.g., points to a toy, cracker, bottle)

gestures (e.g., lifts arms when he or she wants to be lifted up, shakes his or her head to mean "no"

uses physical actions (e.g., takes me to the refrigerator, crawls into my lap, puts a toy in my hand)

says specific sounds for things (e.g., ba for bottle, ma for mama, uh for pick me up)

says specific words for things (e.g., no, bye-bye, night-night, more)

speaks in sentences (e.g., I want it, What's that?, I got potty)

Other:

My child says words. For example, my child says:

family names (e.g., mommy, dada, grandma, grandaddy, brother's or sister's name)

animals (e.g., pet's name, dog, kitty, bird, fish)

food (e.g., milk, juice, cookie, apple, snack)

toys (e.g., ball, dolly, balloon)

daily routines (e.g., go bye-bye, eat, bath, night-night)

body parts (e.g., eye, nose, mouth, hand)

clothing (e.g., shoe, sock, shirt)

Other:

My child's speech is understood by:

household family members (e.g., mother, father, brother, sister)

other family members (e.g., grandparents, aunts, uncles, cousins)

care providers (e.g., babysitter, preschool teacher)

familiar people (e.g., neighbors, friends)

unfamiliar people

My child correctly says the sounds:

/g/ (as in girl, big)

/k/ (as in kite, cat)

"ah" (as in cat)

/eh/ (as in pet)

/i/ (as in hit)

/o/ (as in hot)

/uh/ (as in cup)

/j/ (as in jelly, giraffe)

/s/ (as in city, site)

/a/ (as in cake)

"ee" (as in tree)

"ai" (as in like)

"oh" (as in go)

My child has difficulty saying these sounds:

Other:

Send me a copy of my responses.

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