Speech Development in Children

Today's date: 10/15/2024
Your name: Relationship to child: --------- Mother Father Legal Guardian
Address:
City: State: ZIP Code:
Primary phone: Secondary phone:
Email:
Preferred method of contact: --------- Phone Email

Child who you would like to participate in study

First name: Last name:
Birth date: Chronological age: (must be younger than 180 months)
Sex/Gender: Male Female Non-binary Do not wish to provide

Is American English your child's first and primary language? Yes No
Are other languages spoken in the home? Yes No
If yes, please explain:

Is your child currently or have they previously received speech/language therapy? Yes No
If YES, how old was your child when they started and/or stopped receiving services?
Started: Stopped: