Screener Request Form — Expressive Pediatric Therapy

SPEECH SCREENING REQUEST FORM

This form constitutes a request for a speech-language screening, with parent/guardian permission, to determine if a formal assessment is needed. This screening will include a review of the child’s expressive/receptive language, articulation, fluency and/or voice. Results will be shared with parent(s) and teacher(s) to determine a plan of action.

Child's Name

First Name

Last Name

Child's Date of Birth

YYYY

Parent(s)/Guardian(s)'s Name

First Name

Last Name

Parent(s)/Guardian(s)'s Name

First Name

Last Name

Phone

(###)

###

####

Parent's Email

Daycare/Preschool your Child Attends:

Teacher/ Classroom

Language Spoken At Home

Reason For Screening Request: (check all areas of concern)

Speech (articulation/pronunciation)

Fluency/Stuttering

Voice (e.g., hoarseness, hypernasality, pitch, rate, volume)

Language Skills (grammar, vocabulary, understanding, and comprehension)

Pragmatics/Social Skills

Other

Comments (Please provide specific examples to support request)

check one:

I do give consent to conduct a speech screening.

I do not give consent to conduct a speech screening.

Type your full name to serve as a signature for consent