Speech-Language Screening & Consultation Request

Talk Time Speech and Language Services

Atlanta, GA 30319 Phone: (678) 938-4160 Fax: (678) 623-5289 Email: talktimespeechy@gmail.com
TALK TIME SCREENING CONSENT
Date of Request:

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Date
Date Received:

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Date
Name*

First NameLast Name
DOB*

MonthDayYear
Date
Grade:*
Teacher:
School/Program:*
Parents/Guardians:*
Phone Number:*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

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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)

Misarticulating sounds/SpeechLanguage comprehensionListening skillsVoice differences (such as hoarseness, hypernasality, pitch, rate, volume)Grammar difficultiesExpressive languageDifficulty with fluencyOther
Comments (Please provided specific examples to support request)
I DO give consent to conduct the screening*

YesNo
Parent/Guardian Signature*

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Date*

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Date
Should be Empty:

Talk Time Speech and Language Services