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SPEECH & LANGUAGE INFORMATION

Bentworth School District

Speech & Language Information

Date:*

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Student's Legal First Name*

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Student's Legal Middle Name

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Student's Legal Last Name*

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Date of Birth*

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Age:*

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Contact Information

First Name*

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Middle Name

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Last Name*

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Email 1*

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Email 2

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Mobile Phone*

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Home Phone

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

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Yes

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

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

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Yes

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

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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:

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Parent or Guardian Signature:*

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