School Speech Screening Questionnaire Form
Please complete this form to help us identify and address any speech or language concerns in the school setting. The information collected will be used to support student communication in the classroom.
Student Full Name
*
First Name
Last Name
Student Grade
*
Please Select
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
Other
Teacher's Name
Reason for Screening or Main Speech/Language Concern
*
How long has this concern been noticed?
Please Select
Less than 6 months
6 months to 1 year
Over 1 year
Not sure
Brief Developmental Background (e.g., early milestones, languages spoken at home)
How does this concern affect classroom participation or learning?
Has the student previously received speech or language support?
Yes
No
Not sure
Preferred method of follow-up
Phone call
Email
Written note
No follow-up needed
Additional comments or information
Submit
Should be Empty: