Speech and Language Screener (Parent/Caregiver Version) Ages: 3–8First Name *Last Name *Age *Date of Birth *School Attends *Parent InformationFirst Name *Last Name *Phone Number *Email Address *DateInstructions: Please read each question and circle YES or NO based on your child’s usual behavior. Item YES (1) NO (0) Q1: Is your child easy for family members to understand? *YesNoQ2. Is your child easy for people outside the family to understand? *YesNoQ3. Does your child use sentences about as long as other kids the same age? *YesNoQ4. Does your child follow simple directions without extra help? *YesNoQ5. Does your child answer questions clearly most of the time? *YesNoQ6. Does your child combine words to ask for things or share ideas? *YesNoQ7. Does your child play with language, like singing songs or naming things? *YesNoQ8. Does your child seem frustrated when trying to talk? *YesNoQ9. Does your child stutter or repeat sounds a lot? *YesNoQ10. Does your child have trouble making certain speech sounds? *YesNoTotal ScoreSubmit
