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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?
Student’s Name
Teacher’s Name