Free Resource

Speech & Language Pre-Referral Checklist

For Early Intervention — Before Kindergarten. Fill in the checklist below and submit it to our team. We'll be in touch to discuss next steps.







    Please select any that apply — tap Concerned or Not Concerned for each item.

    1 Communication and Speech

    My child / the child is difficult to understand

    ConcernedNot Concerned

    Uses fewer words than expected for age 4

    ConcernedNot Concerned

    Uses short or simple sentences

    ConcernedNot Concerned

    Has trouble expressing needs or ideas

    ConcernedNot Concerned

    2 Understanding & Language

    Has difficulty following directions

    ConcernedNot Concerned

    Has trouble answering simple questions (what, who, where)

    ConcernedNot Concerned

    Appears not to understand what is being said

    ConcernedNot Concerned

    3 Social Communication & Play

    Has difficulty interacting or playing with peers

    ConcernedNot Concerned

    Rarely initiates communication

    ConcernedNot Concerned

    Limited pretend play or shared play

    ConcernedNot Concerned

    4 Behaviour & Regulation (Related to Communication)

    Becomes easily frustrated or upset

    ConcernedNot Concerned

    Uses behavior (crying, grabbing, avoiding) instead of words

    ConcernedNot Concerned

    Appears withdrawn or avoids group activities

    ConcernedNot Concerned

    Your Checklist Summary