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SPEECH & LANGUAGE INFORMATION

Bentworth School District

Speech & Language Information

Date:*

Answer required for "Date:"

Student's Legal First Name*

Answer required for "Student's Legal First Name"

Student's Legal Middle Name

Answer required for "Student's Legal Middle Name"

Student's Legal Last Name*

Answer required for "Student's Legal Last Name"

Date of Birth*

Answer required for "Date of Birth"

Age:*

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Contact Information

First Name*

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Middle Name

Answer required for "Middle Name"

Last Name*

Answer required for "Last Name"

Email 1*

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Email 2

Answer required for "Email 2"

Mobile Phone*

Number Required

Home Phone

Number Required

Is the student currently enrolled in Speech/Language Therapy?*

Answer required for "Is the student currently enrolled in Speech/Language Therapy?"

Yes

If "yes", please identify the school or facility:

Answer required for "If \"yes\", please identify the school or facility:"

Do you have any concerns about the way your child talks?*

Answer required for "Do you have any concerns about the way your child talks?"

Yes

If you responded "yes" to the previous question, please answer the following questions regarding the specific area(s) of concern:

Answer required for "If you responded \"yes\" to the previous question, please answer the following questions regarding the specific area(s) of concern:"

Articulation - may omit, substitute, or distort certain speech sounds

Voice - may be hoarse, breathy, nasal, may talk too loud or soft

Fluency - may stutter, repeat words, repeat sounds, hesitate, or prolong words

Language - may have difficulty with grammar, vocabulary, etc.

Hearing - may appear inattentive or ask to have information repeated

Please describe any area(s) of concern:

Answer required for "Please describe any area(s) of concern:"

Parent or Guardian Signature:*

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