InterAACtive Speech Therapy
Developmental Speech & Language Questionnaire (Ages2½-6 Years)
This questionnaire helps us better understand your child's communication development. It is not a diagnostic assessment but helps determine whether your child may benefit from additional support, participation in one of our programs, or a comprehensive speech-language evaluation.
Child Information
Child's Name:
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Date of Birth:
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Mes
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Día
Año
Fecha
Age:
*
Today's Date:
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Mes
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Día
Año
Fecha
Parent/Caregiver:
*
Phone:
*
Format: (000) 000-0000.
Email:
*
ejemplo@ejemplo.com
Why are you completing thisquestionnaire?
No concerns—I would just like to learn more about my child's communication.
My child is difficult to understand.
My child is not talking as much as other children their age.
My child has trouble following directions.
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My child has trouble answering questions.
My child gets frustrated when communicating.
My child has difficulty interacting with other children.
My child stutters or repeats sounds/words.
My child has trouble pronouncing words.
My child has been recommended for a speech evaluation.
I want to register my child for a speech group at My Play Place.
Other:
Understanding Language
Does your child...
Follow simple one-step directions?
Yes
Sometimes
No
Follow two-step directions?
Yes
Sometimes
No
Answer simple questions (Who, What, Where)?
Yes
Sometimes
No
Understand everyday routines?
Yes
Sometimes
No
Understand simple stories or books?
Yes
Sometimes
No
Talking & Expressing Ideas
Does your child...
Use words to ask for what they want?
Yes
Sometimes
No
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Use short sentences?
Use short sentences?
Use short sentences?
Use short sentences?
Tell you about something that happened?
Tell you about something that happened?
Tell you about something that happened?
Tell you about something that happened?
Ask questions?
Ask questions?
Ask questions?
Ask questions?
Talk with family during everyday activities?
Talk with family during everyday activities?
Talk with family during everyday activities?
Talk with family during everyday activities?
Speech Sounds
How well can unfamiliar people understand your child?
Almost all of the time
Most of the time
About half of the time
Rarely
Only close family understands my child
Does your child
Rows
Yes
Sometimes
No
Leave sounds off words?
Replace sounds with other sounds?
Become frustrated when others don't understand them?
Repeat sounds, words, or phrases (stuttering)?
Social Communication & Play
Does your child...
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Rows
Yes
Sometimes
No
Respond to their name?
Make eye contact during conversations?
Play with other children?
Take turns during play?
Use pretend play (feeding dolls, cooking, superheroes, etc.)?
Start conversations with others?
Gestures & Nonverbal Communication
Does your child...
Gestures & Nonverbal Communication
Rows
Yes
Sometimes
No
Point to things they want or find interesting?
Wave goodbye?
Shake their head yes or no?
Use facial expressions to communicate feelings?
Early Learning Skills (Ages 4–6)
Does your child...
Rows
Yes
Sometimes
No
Enjoy looking at books?
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Recognize some letters?
Recognize rhyming words?
Retell a simple story?
Medical & Developmental History
Has your child ever...
Had frequent ear infections
Failed a hearing screening
Had a hearing evaluation
Received speech therapy
Received occupational therapy
Received physical therapy
Received Early Intervention (AzEIP or similar)
Used or currently uses AAC (communication device or communication app)
Been diagnosed with Autism Spectrum Disorder
Been diagnosed with ADHD
Been diagnosed with Childhood Apraxia of Speech
Been diagnosed with another developmental condition
If yes, please explain:
Family History
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Does anyone in your immediate family have a history of...
Does anyone in your immediate family have a history of...
Speech delay
Language delay
Reading difficulties
Learning disability
Stuttering
Hearing loss
Autism Spectrum Disorder
None of the above
Parent Observations
How often does your child become frustrated when trying to communicate?
Never
Rarely
Sometimes
Often
Very Often
How concerned are you about your child's communication?
Not Concerned
Slightly Concerned
Moderately Concerned
Very Concerned
What communication skills would you most like your child to improve?
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Is there anything else you would like us to know about your child?
Next Steps
Thank you for completing this questionnaire.
One of our speech-language pathologists will review your responses. Based on your child's developmental profile, we may recommend one of the following:
Participation in one of our speech and language enrichment groups
Continued monitoring of communication development
A free speech and language screening (if appropriate)
A comprehensive speech-language evaluation
This questionnaire is intended as a developmental information gathering tool and is not a diagnostic assessment or formal screening. Recommendations are based on parent report and clinical judgment.
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