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Dear Teacher,

Your student has been referred to me for a speech/fluency evaluation. Your observations will be extremely helpful to me in determining the nature of the problem. Please take a few minutes to answer the questions below; all comments are welcome.

Does this student’s speech differ significantly from same aged peers? *

Does he/she appear to have difficulty getting words out? *

Are there times that the airflow seems blocked when he/she is trying to speak? *

Does he/she repeat words more times than you would expect for a person his/her age? *

Does he/she repeat parts of words more times than you would expect? *

Does he / she prolong or “hold on” to some sounds longer than other? (MMMMmine) *

Is this student aware of any speech differences or difficulties? *

Does this student seem frustrated at times when speaking? *

Has he/she ever told you that it is difficult to speak? *

Does he/she sometimes grimace, frown, blink, widen eyes or show any signs of tension during speech? *

Does he demonstrate bodily movement such as hitting, kicking, swinging, tapping, etc. while trying to get a word out? *

Do classmates find it difficult to understand this child’s speech due to the disfluencies? *

Do other students respond negatively to this student’s speech? *

Is this student teased about speech? *

Does he/she have more trouble talking when reading aloud or during an oral presentation? *

Does he/she have more trouble talking when excited or nervous? *

Is this student avoiding speaking situations due to speech difficulty? *

Is the school speech therapist aware of this student’s speech difficulty? *

Please specify any situations which seem to make your student’s speech more disfluent:

Any other comments?

Student’s Name *

First

Last

Teacher’s Name *

First

Last

Teacher’s Email *

Phone Number

Please indicate best time to contact you

GET IN TOUCH

70 Round Hill Road
Dobbs Ferry, NY 10522
Phone: 914.907.7231
Email: elena@speechjourney.com

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Our goal is for each person that we work with to leave our care with a sense of self-trust, empowerment, and achievement of the goals we’ve set forth together.

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