Preschool Speech Screening Intake Form
Use this form to share the information needed to prepare for a preschool speech screening.
Child Information
Child's Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age
*
Gender / Pronouns
Girl / She
Boy / He
They / Them
Prefer not to say
Prefer to self-describe
Current Preschool / Program Name
*
Primary Language Spoken at Home
*
Parent or Guardian Contact Information
Parent or Guardian Full Name
*
First Name
Middle Name
Last Name
Relationship to Child
*
Please Select
Mother
Father
Grandparent
Foster Parent
Legal Guardian
Other
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Preferred Contact Method
*
Phone
Email
Text
Speech Screening Details
Reason for Screening / Main Concerns
*
Areas of Concern
*
Speech clarity
Language understanding
Vocabulary
Stuttering
Social communication
Other communication concerns
When Concerns Were First Noticed
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Previous Speech/Language Evaluation or Therapy
*
Yes
No
Relevant Developmental, Hearing, Medical, or Educational Notes
Scheduling and Additional Information
Preferred Screening Appointment
*
Does the child attend a preschool or classroom that should receive follow-up coordination?
*
Yes
No
School or classroom contact information (if yes)
Additional comments or special instructions for the screening team
Submit
Should be Empty: