Speech-Language Screening & Consultation Request

TALK TIME SCREENING CONSENT

Date of Request:

Date

Date Received:

Date

Name

First NameLast Name

DOB

Date

Grade:

Teacher:

School/Program:

Parents/Guardians:

Phone Number:

Area CodePhone Number

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

This form constitutes a request for screening, with parent/guardian permission, to determine whether areas of concern can be address within the student’s regular education environment or if a comprehensive referral for a speech-language evaluation is needed. This screening will include a review of the student’s communicative abilities and can address language comprehension and use, articulation, fluency or voice. Results and recommendations will be reviewed with parent and teacher to determine plan of action. A copy will be placed in the speech-language pathologist’s temporary file.

Reason for Screening Request: (check all areas of concern)

Comments (Please provided specific examples to support request)

I DO give consent to conduct the screening

Parent/Guardian Signature

Date

Talk Time Speech and Language Services