Fields marked with * are mandatory
       
 
 
*Name :
*Date :
Instructions: After reading each item, please select the response that best describes how well the statement relates to your child
1. My child speaks well.
2. I worry about my child's speech and/or language skills.
3. My child's communicates primarily via pointing, gesturing, or
4. People frequently tell me that my child has a speech problem.
5. My child has a difficult time being understood by his/her peers.
6. My child has a difficult time being understood by adults other than his family.
7. My child's speech is as good as it should be at his/her age.
8. I think my child's speech is immature.
9. I understand almost everything my child says.
10. I worry about other children teasing my child because of his/her speech.
11. My child has difficulty following directions at home/school.
12. My child is embarrassed or frustrated because of his/her speech.
13. My child does not have difficulties communicating.
14. Other children seem to talk better than my child.
15. My child pronounces most words clearly.
16. I think my child needs speech therapy.
17. My child often has to repeat things in order to be understood
by peers and adults.
18. My child has difficulty understanding what others say
19. My child has difficulty finding the words he wants to say.
20. My child frequently asks "what?"
21. My child frequently gets stuck on words.
22. My child frequently repeats parts of words or entire words.
23. I think my child has difficulty hearing what others say.
24. My child often asks me to repeat things that I ask or say.
25. My child is hesitant about interacting with his/her peers.
26. My child interacts well with peers.
27. I am concerned about my child's behavior.
Word Verification
Type the characters you see in the picture below:


Note : This information is confidential and intended only for use by Speech Pathways, P.C. personnel.
         
   
 
 
   

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