Pediatric Speech Evaluation Request Form
Use this form to request a pediatric speech evaluation for a child and provide the background, concerns, and scheduling information needed to review the request.
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 Identity
Girl
Boy
Non-binary
Prefer not to say
Self-describe
Primary Language(s) Spoken at Home
English
Spanish
Arabic
Chinese (Mandarin)
French
German
Hindi
Korean
Portuguese
Russian
Tagalog
Vietnamese
Other
School / Grade
Parent / Guardian Contact Information
Parent / Guardian Full Name
*
First Name
Middle Name
Last Name
Relationship to Child
*
Please Select
Mother
Father
Legal Guardian
Foster Parent
Other
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Preferred Contact Method
*
Phone
Email
Text Message
Speech / Communication Concerns
Primary concern
*
Which areas are affected?
*
Speech sounds
Language understanding
Expressive language
Stuttering
Voice
Social communication
Feeding / oral motor
Other
When was the concern first noticed?
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Is the concern getting better, the same, or worse?
Getting better
About the same
Worse
Not sure
How does this concern affect communication at home or school?
Medical, Developmental, and Educational History
Pregnancy or Birth Concerns
*
No
Yes
If yes, please describe pregnancy or birth concerns
Concerns About Developmental Milestones
*
No
Yes
If yes, please describe developmental milestone concerns
Hearing Concerns or Prior Hearing Test
No concerns
Concerns, not yet tested
Concerns, hearing test completed
Unknown
Date of Hearing Test
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hearing Test Results or Details
Previous Speech Therapy or Related Services
No
Yes
If yes, please describe previous speech therapy or related services
Relevant Diagnoses or Developmental Conditions
Autism spectrum disorder
ADHD
Learning disability
Intellectual disability
Hearing loss
Cerebral palsy
Genetic condition
Other
Current School or Early Intervention Services
Other Specialists Involved
Scheduling and Referral Details
Preferred Appointment Times
*
Morning
Afternoon
Evening
Preferred Appointment Days
*
Weekdays
Weekends
Location Preference
Please Select
Clinic
School
Telehealth
Home
Other
Referral Source
*
Please Select
Pediatrician
Teacher
Parent/Guardian
Therapist
Self
Other
Referring Provider Name
Referring Provider Contact Information
Please enter a valid phone number.
Format: (000) 000-0000.
Urgency of Request
*
Please Select
Routine
Soon
Urgent
Acknowledgment and Submission Details
Confirmation
*
I confirm that the information provided is accurate and I am authorized to submit this request on behalf of the child.
Additional Notes or Questions
Submit Request
Should be Empty: