Speech Therapy Rehabilitation Assessment Form
Please complete this assessment form to help us understand your speech therapy rehabilitation needs.
Full Name
*
First Name
Last Name
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reason for Referral
*
Speech sound difficulties
Language delay
Stuttering
Voice issues
Other
Primary Communication Method
*
Verbal speech
Sign language
Augmentative/Alternative Communication (AAC)
Other
Areas of Concern (Select all that apply)
*
Articulation
Fluency
Language comprehension
Expressive language
Voice
Social communication
Other
Please rate the following areas:
*
Rows
Not a concern
Mild concern
Moderate concern
Severe concern
Speech clarity
1
2
3
4
Language understanding
5
6
7
8
Ability to express needs
9
10
11
12
Social interaction
13
14
15
16
Fluency
17
18
19
20
Overall Communication Ability
*
Very limited
1
2
3
4
Excellent
5
1 is Very limited, 5 is Excellent
Frequency of Communication Challenges
*
Rarely
1
2
3
4
Very frequently
5
1 is Rarely, 5 is Very frequently
Therapist Observations or Additional Notes
Submit Assessment
Should be Empty: