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SPEECH/LANGUAGE SERVICES SCREENING FORM

DUE DATE: Please return this form to:

Student: Grade: Language Screening D.O.B.:

Building: Teacher:

Procedure:_______________________________________

_____Pass

_____Fail

Comments:____________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Articulation Screening Procedure:_______________________________________ _____Pass _____Fail Comments:____________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Voice Screening Procedure:_______________________________________ _____Pass _____Fail Comments:____________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Fluency Screening Procedure:_______________________________________ _____Pass _____Fail Comments:____________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________

_______________________________________________ Signature of Speech Therapist

______________________ Date

(Revised 8/96)

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