Initial Screening - SPEAK

Name of person completing this form:

Relationship to the child:

Address:

City, State, ZIP Code:

Phone:

Email:

Preferred contact:

Phone

Child's first name:

Child's last name:

Child's age:

Child's birth date:

Does your child have a medical diagnosis of cerebral palsy or something related to cerebral palsy?

Yes

List your child’s specific medical diagnoses:

Is your child currently receiving any services or interventions (e.g., special education, physical therapy, occupational therapy, speech or language therapy, vision therapy)?

Yes

Please list the services your child receives:

Is your child’s first and primary language English?

Yes

Are there any other languages spoken in the home?

Yes

Please list the other languages spoken in the home:

Is your child able to use their hands to point?

Yes

Is your child able to use speech to communicate?

Yes

Is your child hard for others to understand at least some of time?

Yes

Describe how your child communicates with you. Be sure to mention the different modes they use (e.g., verbal speech, gestures, AAC system (speech generating device, eye gaze etc.), and/or sign-language):

Do you have any concerns about your child's hearing, or have they been diagnosed with hearing loss?

Yes

If yes, please describe:

How did you hear about our study?