Preschool
Child’s Name / Date of Birth: / Age:
Teacher: / Classroom/School
This form completed by: / Date:
Check any item that describes this child: Mark with a T if it is teacher observed. Mark with a “P” for parent input.
A. Expressive Skills (articulation and language)
1. / Speech is difficult to understand
2. / Mispronounces or omits specific sounds; list here:
3. / Often uses incomplete sentences (e.g. :Put car on chair. Boy run fast.”)
4. / Often uses incorrect grammar (e.g. “Me got two shoe. Him felled down”).
5. / Has trouble imitating words/phrases
6. / Has trouble asking questions
7. / Has trouble organizing and expressing ideas
8. / Seems to have limited vocabulary
9. / Seems to have trouble thinking of the word(s) he/she wants to say (may be especially evident when asked to name a series of pictures or objects).
B. Receptive Skills (auditory comprehension/processing)
1. / Seems unusually dependent on visual cues (gesturing, pointing)
2. / Seems confused when giving directions
3. / Is slow to process (and act on) instructions, requests, etc.
4. / Has difficulty attending to activities that center on listening (stories, records).
5. / Has difficulty remembering directions, sequences, etc.
6. / Has limited comprehension of words, ideas, and information.
7. / Has difficulty answering questions in class
8. / Does not appear to understand many questions in class
9. / Seems easily confused by surrounding noise, conversation, etc.
C. Communication Interaction
1. / Seems reluctant to talk to adults and/or peers
2. / Is inattentive to most statements directed towards him/her
3. / Often avoids eye contact with adults and/or peers
4. / Does not seem to enjoy physical contact
5. / Prefers to play by self most or all of the time
6. / Often makes comments inappropriate to the situation
7. / Often echoes back what has just been said to him/her
8. / Has trouble taking turns in a conversation
D. Fluency (stuttering)
1. / Has had considerable dysfluency for how long / or since when?
2. / Frequently repeats: syllables / words / phrases
3. / Seems to struggle to get words out
4. / Seems tense or concerned about the way he/she speaks
5. / Often prolongs sounds (e.g. “mmmmmmmman” or “ssslide”)
6. / Makes facial expressions that show muscle tension and/or frustration (squints eyes, tightens jaw)
E. Voice
1. / Voice pitch is too high or low
2. / Voice has rough, hoarse quality which has persisted more than two weeks
3. / Voice is excessively loud or soft much of the time
4. / Voice has a nasal quality
F. Other
1. / Has known hearing loss
2. / Has suspected hearing problem
3. / Seems unaware of environmental sounds (phone ringing, book dropping, etc.)
4. / Has short attention span
5. / Has trouble chewing or swallowing
6. / Drools
7. / Mouth is usually open
8. / Failed hearing screening / Results:
Please note any other concerns you may have about the way this child communicates.
Recommendations:
Special Service #6ENG Revised 2/22/2018