Child Speech Evaluation Survey
Please complete this survey to help assess your child's speech and communication abilities.
Child's Full Name
*
First Name
Last Name
Child's Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Parent/Guardian Name
*
First Name
Last Name
Parent/Guardian Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Primary language(s) spoken at home
*
Has your child ever received speech or language therapy before?
*
Yes
No
Please rate your child's abilities in the following areas:
*
Rows
Below Age Level
At Age Level
Above Age Level
Understanding spoken language
1
2
3
Expressing thoughts with words
4
5
6
Pronouncing words clearly
7
8
9
Following directions
10
11
12
Using correct grammar
13
14
15
Participating in conversations
16
17
18
How often does your child experience any of the following? (Select one per row)
*
Rows
Never
Sometimes
Often
Repeats sounds or words (stuttering)
19
20
21
Is difficult to understand
22
23
24
Struggles to find the right words
25
26
27
Mixes up word order in sentences
28
29
30
Leaves out words when speaking
31
32
33
Overall, how would you rate your child's speech and communication skills?
*
1
2
3
4
5
Are there any specific concerns you would like to share about your child's speech or language development?
Submit
Should be Empty: