🗣️
Healthcare & Wellness
Speech Therapy Screening
Parents describe their concerns and record a short speech sample, so your therapists can screen and prioritise before the first visit.
Use this template13 fields · Free · Customize before publishing
What this form looks like
Preview · not interactiveSpeech Therapy Screening
Parents describe their concerns and record a short speech sample, so your therapists can screen and prioritise before the first visit.
Parent or guardian name*
Email address*
Screening results and appointment options go here.
Child's name*
Child's date of birth*
Pick a date📅
Main language spoken at home*
Select…▾
If your child hears more than one language, pick the strongest and mention the others in the notes at the end.
What are you noticing?*
Pronouncing sounds (articulation)
Stuttering or getting stuck on words
Few words for their age (vocabulary)
Understanding what is said to them
Tell us a little more
Describe what you are noticing in your own words.
Roughly what age did you first notice concerns? (years)
e.g. 3
Record a short speech sample*
⬆ Drop a file or click to upload
This gives our therapists real clinical signal before your first visit.
Has your child had speech therapy before?*
Yes
No
Where, and roughly when?
e.g. school-based therapy last year
Has your child's hearing been tested?*
Yes — hearing was fine
Yes — a concern was found
Not yet
Hearing can affect speech, so this helps us rule things in or out.
What would you love to see improve? (optional)
Submit