Speech & Language Screening Request

We offer complimentary speech and language screenings for students at participating schools. If you're a teacher or parent with concerns about a child’s communication development, you can easily request a screening using the QR code provided by your school or by completing this form.

Student Name

First Name

Last Name

School Location

Phone

(###)

###

####

Language Spoken at Home

What concerns do you have about the child's speech and language?

My child produces speech sound errors or is difficult to understand.

My child has difficulty understanding directions, stories or other materials.

My child has difficulty expressing his or her thoughts and ideas clearly.

My child uses an AAC device or would benefit from using one.

My child has difficulty understanding social situations and making friends.

Other

Has the child ever received speech therapy services?

List any other concerns or information here:

I understand that the screening will last approximately 20-25 minutes.

Yes

I give InterAACtive Speech Therapy permission to complete the screening and share the results with the person whose contact information appears above.

Agree

Name of person completing this form:

Relationship to Student

Speech & Language Screening Request

Put the ACTIVE in InterAACtive.