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Speech and Language Screening Request Form 2021-2022
Please complete the form below to request a speech and language screening. Please remember it is your responsibility to contact the parent/guardian prior to the screening.
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* Indicates required question
Email
*
Your email
Student Name:
Your answer
Date of Birth:
MM
/
DD
/
YYYY
Grade:
Your answer
Teacher:
Your answer
Have you communicated your concerns with the parent/guardian and obtained verbal or written consent for the speech therapist to complete a screening? *
*
Yes
No
Other...
Comments from Parent:
Your answer
Please Check your area(s) of concern
Receptive/Expressive Language
Articulation (speech sound skills)
Fluency (stuttering)
Pragmatics (social skills)
Voice
If you checked Articulation/Phonology:
No concerns
The child leaves off or adds sounds to words.
The child substitutes sounds for correct sounds.
The child's articulation errors are seen in their writing, affecting their spelling.
The child avoids speaking in class because of their speech errors.
The child avoids communicating with peers because of speech errors.
The child's speech is difficult for peers and adults to understand.
If you checked Receptive Language:
No Concerns
The child struggles with following oral directions or putting events in order of occurrence .
The child has difficulty understanding what they have read.
The child takes a long time to process verbal information.
The child has difficulty answering questions about a story read.
The child struggles with understanding classroom vocabulary.
If you checked Expressive Language:
No Concerns
The child speaks/writes, using short, choppy sentences that are incomplete at times.
The child takes a long time to process verbal information.
The child has difficulty answering questions about a story read.
The child has a difficult time expressing their ideas, asking for help, getting their wants and needs met.
If you checked Voice:
No concerns
The child has an unusual voice quality (raspy, consistent hoarseness, strained-sounding breathiness or nasally).
The child speaks in an unusually loud/soft voice.
If you checked Fluency (stuttering):
No Concerns
The child frequently stutters when speaking.
The child consistently uses filler words such as "uh", "um", "ah", or "you know" when speaking.
The child speaks using an increased rate of speech, decreased rate of speech or monotonous.
The child expreiences interrupted flows of speech or blocks, while speaking.
Pragmatics (Social Language)
No Concerns
The child has difficulty conversing with or initiating conversation with peers and adults.
The child is unable to stay on topic or transition appropriately to new topics, when speaking.
The child has difficlty answering/asking quesitons appropriatley.
The child has difficulty itnerpreting facial expressions or body cues.
The child does not interact appropriatley with peers and/or adults.
Other Observed Concerns:
Your answer
Date Completed by SLP
MM
/
DD
/
YYYY
Recommendations:
Choose
Pass No Concerns at this time
Fail Begin Intervention
Follow up recomended
SLP Comments:
Your answer
Submit
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