Parent Name *

First Name

Last Name

Child's Name *

First Name

Last Name

Child's Date of Birth *

MM

DD

YYYY

Please check all areas of concern *

Misarticulating Sounds/Speech

Grammar difficulties

Language comprehension

Expressive language

Listening skills

Difficulty with fluency

Voice differences (such as hoarseness, hypernasality, pitch, rate, volume)

General check, no concerns

Other

Parent Consent *

I am the parent/legal guardian of the child named above, and give permission for my child to participate in a speech and language screening. I understand that this is not a formal or comprehensive evaluation, but a brief screening to help determine whether a referral for further assessment may be recommended. I also understand that this service is provided free of charge and is not eligible for insurance reimbursement.

By checking this box, I confirm that I am the parent/legal guardian of the child named above and that I consent to this screening under the terms described.