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About Us
Services
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Assessments
Speech & Language
Learning Disabilities
Contact Us
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Speech & Language Therapy Screening Form
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Speech & Language Therapy Screening Form
Name
*
Email Address
*
Contact Number
*
Child’s Age
Select
18–24 months
2–3 years
3–4 years
4 years and above
Child’s Gender
Select
Male
Female
Prefer not to say
Other
Primary Concern
Select
Not speaking yet
Speaking few words
Unclear speech
Difficulty understanding language
Age When Concern Was First Noticed
Select
Before 2 years
2–3 years
3–4 years
After 4 years
Current Speech Level
Select
No words
Single Words
Short phrases
Full sentences
Understanding of Instructions
Select
Rarely understands
Understands simple commands
Understands most instructions
Age-appropriate
Communication Method Used
Select
Gestures/pointing
Sounds/babbling
Words
Sentences
Social Interaction & Eye Contact
Select
Very limited
Inconsistent
Mostly appropriate
Age-appropriate
Daily Screen Time (Mobile / TV / Tablet)
Select
None/minimal
1–2 hours
>2 hours
Age When Screen Time Started
Select
Before 1 year
1–2 years
2–3 years
After 3 years
Response to Name & Sounds
Select
Rarely responds
Sometimes responds
Mostly responds
Always responds
Previous Therapy or Assessment
Select
None
Speech therapy only
Developmental assessment
Multiple therapies
Submit
Contact Details
+92-3124982158
info@vicakids.com
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