Appendix DA-D1

SPEECH SCREENING REQUEST FORM
To be completed by Teacher/Parent

Name of Child: 	 Date of Birth: 	 Classroom Program: 			
Person Completing Form: 		Date:  	
Results of ASQ-3:     Pass    Rescreen     Refer (Note: If   the speech  screening  indicates that the child would benefit from a speech evaluation, a copy of the child's ASQ-3 will be needed to show that the child is developing age-appropriately in all other areas. If the child scored within the referral range in one or more areas on the ASQ-3 refer for a full evaluation.)

What are your concerns with this child's speech?

I give permission for my child's speech to be screened by a speech therapist from Midwestern Intermediate Unit 4 (IU 4) or ARIN Intermediate Unit 28 (IU 28).

Parent's Signature: 	_

RESULTS OF SPEECH SCREENING

Completed by the Speech Therapist then forwarded directly to the Special Services Coordinator.

Name of Child: 	Classroom: 	_ Results of speech screening:
 		According to the speech screening tool, this child's errors are developmental.

 		According to the speech screening tool, this child would benefit from a speech evaluation.

Additional information:  	

Signature of Therapist: 	Date: 	_