Speech and Language Pre-Evaluation Form

CP1. In the past 3 months, have you had concerns about your child's speech clarity?*

CP2. In the past 3 months, have you had concerns about your child's understanding of language?*

CP3. In the past 3 months, have you had concerns about your child's ability to express wants and needs?*

CP4. In the past 3 months, has anyone else (teacher, pediatrician, family member) raised concerns about communication?*

CP5. In the past 3 months, has your child become frustrated when trying to communicate?*

CP6. In the past 3 months, have communication challenges affected daily routines (meals, play, bedtime, outings)?*

CP7. Does your child currently receive speech-language therapy or early intervention services?*

CP8. Has your child had a prior speech-language evaluation?*

CP9. Has your child lost words or communication skills they previously used?*

CP10. Before 12 months of age, did your child use babbling sounds like "ba-ba" or "ma-ma"?*

CP11. Before 16 months of age, did your child use at least one meaningful word?*

LU1. In the past 3 months, has your child used words, signs, or gestures to communicate needs?*

LU2. In the past 3 months, has your child combined two or more words/signs/gestures to communicate ideas?*

LU3. In the past 3 months, could familiar adults usually understand your child?*

LU4. In the past 3 months, could unfamiliar adults usually understand your child?*

LU5. In the past 3 months, has your child followed simple one-step directions (for example: "Give me the ball," "High-Five!," or "Bring your cup")?*

LU6. In the past 3 months, has your child followed two-step directions (for example: "Pick up the truck and put it on the table," "Go to the kitchen and get your shoes," or "Touch your nose, then clap your hands")?*

LU7. In the past 3 months, has your child pointed, shown, or brought items to share attention with you?*

LU8. In the past 3 months, has your child engaged in back-and-forth communication (sounds, words, signs, gestures, or eye contact)?*

SP1. In the past 3 months, has your child imitated sounds, words, gestures, or actions during play?*

SP2. In the past 3 months, has your child engaged in pretend play (for example, feeding a doll or acting out routines)?*

SP3. In the past 3 months, has your child initiated interaction with caregivers or peers?*

SP4. In the past 3 months, has your child responded when their name is called?*

SP5. In the past 3 months, has your child maintained attention to a shared activity for at least a few minutes?*

SP6. In the past 3 months, has your child used communication to repair misunderstandings (repeat, rephrase, gesture, or show)?*

HM1. Has your child had a hearing screening in the last 12 months?*

HM2. Has your child had frequent ear infections (3+ in 6 months or 4+ in 12 months)?*

HM3. Does your child often cover ears, avoid noisy places, or become distressed by everyday sounds?*

HM4. Has your child had feeding, swallowing, or oral-motor concerns?*

HM5. Was your child born preterm or with any significant birth complications?*

HM6. Does your child have any diagnosed medical, developmental, or neurological conditions?*

FC1. Is more than one language used in your home?*

FC2. Would you like support strategies that include your home language(s)?*

FC3. In the past 3 months, have caregiving responsibilities or scheduling made it hard to attend in-person appointments?*

FC4. Do you feel confident using language-building strategies during daily routines right now?*

FC5. Would you like coaching for communication routines during meals, play, and transitions?*

FC6. Do you have access to a device and internet for telehealth sessions?*

CPP1. Would you like a caregiver-led home plan with weekly practice activities?*

CPP2. Would you like referrals for additional services if needed?*