Speech Questionnaire
    • Access Code 

  • Speech Questionnaire

    Therapy West
  • Date of Birth*
     - -
  • Format: (000) 000-0000.
  • 1. Has your child had a previous speech and language evaluation?*
  • 2. Has your child previously had speech and language therapy?*
  • 3. Do any family members have hearing or speech/language difficulties?*
  • 3. Do any family members have hearing or speech/language difficulties?*
  • 6. Does your child respond to his/her name?*
  • 7. Does your child point to objects when asked?*
  • 8. Does your child follow simple directions?*
  • 9. Does your child get objects from another room when asked?*
  • 10. Does your child point to body parts when asked?*
  • 11. Does your child point to pictures in books when asked?*
  • 12. Does your child answer simple questions?*
  • 13. Does your child point to family members when asked?*
  • 14. Does your child understand prepositions (in, on, under, next to)?*
  • 15. Does your child understand color & size words (red, big/small)?*
  • 16. Does your child engage in pretend/imaginary play?*
  • 17. Does your child socialize/play with other children?*
  • 18. Does your child repeat sounds/words when speaking?*
  • 19. Does your child have difficulty learning/retaining new information?*
  • 20. Does your child have difficulty learning/using new words?*
  • 21. Does he/she have difficulty pronouncing any sounds?*
  • 24. Is your child easily frustrated when he/she is not understood?*
  • 24. Is your child easily frustrated when he/she is not understood?*
  • 25. Is your child aware of his/her no communication difficulties?*
  • Should be Empty: