Speech Therapy Form Clinic Location Child has appointment scheduled at* Pooler Richmond Hill Name* Date of Birth* Month Day Year Today's Date* Month Day Year If your child is being evaluated for ST (speech therapy)… Please check any of the following performance skill areas that apply to your child.Language (Listed in developmental order from Preschool to School Age) Responds to his/her name Repeats new words Puts 2 words together Gets others’ attention using words Greets others arriving or leaving (waving or verbally) Takes turns in a “conversation” Asks for help Says 3 to 4 word sentences Follows 1-2 step directions Answers “yes/no” questions Answers “wh” questions (what, where, why, how) Uses pronouns correctly (I, me, we) Participates in pretend play/plays appropriately with peers Uses complete sentences Recall and tell about everyday events Uses words to express feelings Has a similar vocabulary to children his/her age Has difficulty with reading comprehension Has poor phonological awareness skills (letter-sound correspondence, rhyming words, blending sounds to make words) Understands figures of speech (“butterflies in my stomach”) Has difficulty following multi-step directions Has trouble thinking of the right word to say Has trouble saying what he/she is thinking and getting to the point Knows when a listener does not understand his/her message Maintains eye contact FLUENCY & VOICEMy child stutters (please check next to types of dysfuencies observed) Repeats whole words “why, why, why, why” Repeats parts of words Prolongs or holds onto a sound “w-------hy” Repeats sounds “w-w-w-w-why” Prolongs or holds onto a sound “w-------hy” Repeats phrases “I want, I want” Blocks – sounds and airflow are shut off If your child stutters, is he/she aware or frustrated by moments of dysfluency? Yes No If your child stutters, does he/she exhibit physical movements accompanying movements of stuttering? (stomping foot, blinking eyes, tapping leg) Yes No Has atypical vocal quality- (please select) Hoarse Hypernasal Hypoonasal (stuffed up) Monotone Unusual pitch for his/her age Speaks Too quietly Too rapidly ArticulationHas trouble making particular speech sounds? (PLEASE LIST) Leaves sounds out of words- Beginning Middle End Has difficulty producing multisyllabic words?* Yes No How much of your child’s speech do you understand?* 10% or less 11-24% 25-50% 51-74% 75-100% How much of your child’s speech do others understand?* 10% or less 11-24% 25-50% 51-74% 75-100% Does your child demonstrate frustration when he/she is not understood?* Yes No Is your child able to correct errors when given a correct model of sound or word?* Yes No Δ