Access Code
Please enter the access code provided to fill out the form
*
Back
Next
Speech Questionnaire
Therapy West
Client Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Parent or Caregiver name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
1. Has your child had a previous speech and language evaluation?
*
Yes
No
2. Has your child previously had speech and language therapy?
*
Yes
No
3. Do any family members have hearing or speech/language difficulties?
*
Yes
No
3. Do any family members have hearing or speech/language difficulties?
*
Yes
No
4. What is your child's most frequent means of communication? (looking at objects, babbling, grunting)?
*
5. Does your child use words consistently to communicate? If so, please provide number of words used consistently?
*
6. Does your child respond to his/her name?
*
Yes
No
7. Does your child point to objects when asked?
*
Yes
No
8. Does your child follow simple directions?
*
Yes
No
9. Does your child get objects from another room when asked?
*
Yes
No
10. Does your child point to body parts when asked?
*
Yes
No
11. Does your child point to pictures in books when asked?
*
Yes
No
12. Does your child answer simple questions?
*
Yes
No
13. Does your child point to family members when asked?
*
Yes
No
14. Does your child understand prepositions (in, on, under, next to)?
*
Yes
No
15. Does your child understand color & size words (red, big/small)?
*
Yes
No
16. Does your child engage in pretend/imaginary play?
*
Yes
No
17. Does your child socialize/play with other children?
*
Yes
No
18. Does your child repeat sounds/words when speaking?
*
Yes
No
19. Does your child have difficulty learning/retaining new information?
*
Yes
No
20. Does your child have difficulty learning/using new words?
*
Yes
No
21. Does he/she have difficulty pronouncing any sounds?
*
Yes
No
22. What percentage of the time do you feel you understand your child?
*
23. What percentage of the time do you feel others understand your child?22. What percentage of the time do you feel you understand your child?
*
24. Is your child easily frustrated when he/she is not understood?
*
Yes
No
24. Is your child easily frustrated when he/she is not understood?
*
Yes
No
25. Is your child aware of his/her no communication difficulties?
*
Yes
No
Signature
*
Submit
Should be Empty: