Dear XX,
Please complete the following speech and language questionnaire for STUDENT as soon as
possible. Your feedback is essential to his/her speech and language evaluation and will help me
determine appropriate supports, if necessary, for this student.
If you do not have any concerns and feel this student is functioning appropriately with the
supports he/she already has, you can skip the questions and write that in the "Additional
Comments" section.
Thank you for your time!
Directions:
- Click "REPLY" to this email
- Scroll down and put "x" in the appropriate boxes of the questionnaire below
**This is all done directly via this email. You do not need to create a new document, save
anything, or attach anything!**
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Speech and Language Questionnaire
Please review each section and check all that apply by typing an "X" into the
corresponding highlighted space.
Articulation and Speech Rate/Clarity
The manner in which speech sounds are produced; the capacity to speak clearly and with an
even, natural rate.
___There are no significant concerns at this time. (If checked, move on to next section)
___The student is hard to understand, mispronounces words, and/or omits sounds in words.
___The student is:
___Fairly intelligible (intelligible only if topic known; others have consistent difficulty
understanding) (50-79%)
___Unintelligible (almost never understood in conversational speech) (<50%)
___The articulation errors are drawing negative and undue attention to the student
___The student sounds less mature because of the articulation errors
___There is evidence of the student experiencing stigma in the lunch room, at recess, or in
electives (art, music, etc.) because of the articulation errors, such as being teased, bullied,
avoided or shunned by peers
___The student participates minimally or rarely in class during oral activities (answering
questions, taking part in discussions, interacting with peers) due to articulation difficulties
___The student is not confident reading aloud or in small group settings due to articulation errors
___When the student is required to give an oral presentation in class, the articulation errors
negatively impact his/her delivery of the spoken material
___The student expresses frustration about his/her difficulty speaking properly
___The student’s parents express(ed) concern about his/her difficulty speaking
___The student uses excessive “um,” “uh”, “you know” “a”, etc. when speaking
___The student speaks either: ___too quickly or ___too slowly