Child Speech Assessment Form
Please complete this form to help us assess your child’s speech and language abilities. All information is strictly for assessment purposes.
Child's Full Name
*
First Name
Last Name
Child's Age
*
Primary Language Spoken at Home
*
Please Select
English
Spanish
Mandarin
Arabic
Other
Who is completing this form?
*
Parent or Guardian
Teacher
Speech-Language Pathologist
Other
What are your main concerns about the child’s speech or language?
*
Difficulty pronouncing certain sounds
Limited vocabulary
Difficulty understanding instructions
Stuttering or hesitations
Difficulty forming sentences
Difficulty with social communication
Other
How clearly can the child be understood by unfamiliar listeners?
*
Always understood
Usually understood
Sometimes understood
Rarely understood
Rate the child’s ability in the following areas:
*
Rows
Not at all
Somewhat
Age-appropriate
Above average
Pronunciation of words
1
2
3
4
Sentence formation
5
6
7
8
Understanding spoken language
9
10
11
12
Expressing ideas verbally
13
14
15
16
How often does the child repeat words or phrases (stuttering)?
*
Never
Rarely
Sometimes
Often
How well does the child interact with peers?
*
Very well
Adequately
With some difficulty
Significant difficulty
Any additional comments or relevant background information?
Submit Assessment
Should be Empty: