Speech/Language Evaluation Parent Questionnaire
  • Speech/Language Evaluation Parent Questionnaire

    You have requested a speech and language evaluation for your child. In preparation for the examination, we need information to assist in planning for and conducting a complete evaluation. Please answer the questions as fully and accurately as possible. If you are not sure of a particular date, you can write the approximate date and put a question mark after that. Your family physician may be able to provide you with certain information, or consult the child’s baby book, if available. All the following information is for the confidential use of All in 1 SPOT with Theratalk. Please contact us if you have any questions. We look forward to working with you!
  • Family Information

  •  - -
  • Parent/Caregiver #1

  • Format: (000) 000-0000.
  • Parent/Caregiver #2

  • Format: (000) 000-0000.
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  • REASON FOR REFERRAL

  • BIRTH AND DEVELOPMENTAL HISTORY

  • DEVELOPMENTAL MILESTONES

  • MEDICAL/SOCIAL/EMOTIONAL HISTORY

  • AUDIOLOGICAL

  • FEEDING ISSUES

  • SPEECH &LANGUAGE HISTORY

  • All information will be held in strict confidence and not released to any person(s) without explicit authorization nor shared with any unauthorized person.
    All in 1 SPOT with TheraTalk prohibits discrimination on the basis of race, religion, color, national or ethnic origin, age, sex, sexual orientation, marital status, or disability.


    EVERY CHILD DESERVES A VOICE. WE ARE HERE TO HELP YOU AND YOUR CHILD EVERY STEP OF THE WAY!


    Updated September 2023

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