Literacy Evaluation Questionnaire for Caregivers

Not sure where to start? You're not alone—and that's exactly why we created this screener.

At Dynamic Therapy Specialists, our licensed speech-language pathologists specialize in identifying and treating dyslexia. Simply answer a few quick questions, and our team will review your responses and reach out with personalized recommendations for next steps.

Child's Name

First NameLast Name

Child's Date of Birth

Date

Person Completing This Form

First NameLast Name

Relationship to Child

Related Family History: Children with dyslexia and other related learning disorders often have a family history of reading or spelling challenges. Please respond whether a person in your child's family has a history of:

Rows	Yes	No	Unsure
Difficulty learning to read
Diagnosis of dyslexia (or relevant)
Ongoing spelling difficulties
Diagnosed learning disability other than dyslexia
Avoiding reading or writing tasks
Difficulty learning a foreign language
Speech (articulation) disorder diagnosed

Academics: Obtaining information about how your child performs academically at school and at home is essential in understanding the entire picture and planning for intervention. Please complete these questions as thoroughly as possible by checking what best describes your child (you can select multiple).

Check the things that you think are easiest for your child to do.

On Average, how long does it take your child to do homework and what kind of support is needed, if any?

How would your child's teacher describe him/her?

Below is a screener for language/literacy disorders. Rate your child compared to children the same age. Compared to other students of the same age, select the number to show how good your child is at...

Rows	1 (Not Good)	2	3	4	5	6	7 (Very Good)
Understanding school vocabulary words
Using school vocabulary words when talking
Figuring out new words when reading
Spelling words correctly when writing
Understanding a story when listening
Telling a story that makes sense
Understanding a story when reading
Writing a story that makes sense

Literacy Development occurs in a predictable sequence and red flags are raised during an early period of development. Please indicate any of the characteristics that did in the past or is currently describing your child.

Rows	This describes my child	Not age appropriate or does not describe child
Difficulty learning nursery rhymes
Difficulty recognizing rhyming words
Trouble clapping (or counting) syllables in words
Difficulty identifying sounds in words
Difficulty learning letter names
Difficulty learning letter sounds
Confuses letters that look similar (b/d/p/q)
Difficulty remembering sequences (days of week, alphabet)
Difficulty learning to read sight words
Difficulty learning to spell sight words
Difficulty blending sounds to create words
Guesses at words instead of sounding them out
Mispronounces words but not due to a speech disorder (vench/bench, aminal/animal)
Has had more than 2 ear infections
Makes articulation/Speech errors
Letter or number reversals past the end of 1st grade

Please upload any past evaluations. Examples include DIBELS, STAR, End of Year School Testing, LEAP, Report Cards, Psychoeducational Evaluation, Dyslexia Evaluation, etc.

Is there anything else that you would like to share about your child that would best help us determine next steps?