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Speech & Language Pre-Referral Checklist — School-Age

For School-Age Children. 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 Understanding & Language

    Has difficulty following directions

    ConcernedNot Concerned

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

    ConcernedNot Concerned

    Has difficulty learning new vocabulary

    ConcernedNot Concerned

    Understanding stories or explanations

    ConcernedNot Concerned

    Has trouble expressing needs or ideas

    ConcernedNot Concerned

    Difficulty in using age-appropriate grammar

    ConcernedNot Concerned

    Difficulty with developing literacy skills as expected

    ConcernedNot Concerned

    2 Speech Production

    Speech difficult for unfamiliar listeners

    ConcernedNot Concerned

    My child is above 5 years of age, and makes errors for K, G, L, S, Z, SH, CH, J, R sounds

    ConcernedNot Concerned

    Child shows frustration when speaking

    ConcernedNot Concerned

    3 Social Communication & Play

    Has difficulty interacting or playing with peers

    ConcernedNot Concerned

    Difficulty with initiating communication

    ConcernedNot Concerned

    Difficulty to take conversational turns

    ConcernedNot Concerned

    Understanding social cues

    ConcernedNot Concerned

    4 Fluency and Voice Related

    Repeats or stretches the sounds or words while speaking

    ConcernedNot Concerned

    Presents with speech blocks or tension while speaking

    ConcernedNot Concerned

    Concerns with the voice quality

    ConcernedNot Concerned

    Your Checklist Summary