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Speech-Language History
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Child's Full Name
Your answer
Please describe your child's communication difficulties:
Your answer
Has your child previously received treatment?
Yes
No
If yes when and where:
Your answer
Is your child aware or frustrated/anxious about these difficulties?
Yes
No
Clear selection
How does your child prefer to communicate?
Your answer
Please share an example of a typical sentence said by your child.
Your answer
What is the total number of words your child has in their vocabulary?
Less than 10 words
10-25 words
Uses 2-word combinations (i.e. Daddy go)
Uses 3-word combinations (i.e. Mommy go out)
Uses 4-6 word sentences (i.e. My dog's name is Annie.)
Speaks in full sentences
Typical for children his/her age
Clear selection
Please Identify those behaviors your child demonstrates consistently
repeats sounds, words or phrases over and over
difficulty answering questions
difficulty understanding what you are sayng
difficult to understand
plays alone for unreasonable lengths of time
poor eye contact
easily frustrated / impulsive
easily distracted / short attention
separation difficulties or anxiety
Clear selection
Please list any speech errors your child may use (i.e. says /w/ for /r/, can't say /th/)
Your answer
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