Secondary School Screen

Speech, Language & Communication Skills

Please complete the survey form. Your feedback will support clearer assessment planning and reveal the areas that should receive greater focus.

Secondary School Screen

Speech, Language & Communication Skills

Please complete the survey form. Your feedback will support clearer assessment planning and reveal the areas that should receive greater focus.

UL Clinic Systems

Child Information

First Name *

Last Name *

Email *

Child Information

Additional Languages *

Age *

Therapist *

School Information

School Name *

Class Teacher *

Year/Form Group *

Area of Language

Is Attention and Listening an area of concern? *

Yes

Area of Language

Attention and Listening

Has trouble focusing in whole class learning *

Never

Sometimes

Often

Always

Comments

Area of Language

Attention and Listening

Has trouble keeping up with the pace of whole class learning *

Never

Sometimes

Often

Always

Comments

Area of Language

Attention and Listening

Has trouble focusing within a small group setting *

Never

Sometimes

Often

Always

Comments

Area of Language

Attention and Listening

Has trouble focusing in 1:1 settings *

Never

Sometimes

Often

Always

Comments

Area of Language

Attention and Listening

Has trouble focusing on learning tasks till completion *

Never

Sometimes

Often

Always

Comments

Area of Language

Attention and Listening

Has difficulty focusing on the learning stimulus e.g. the whiteboard, workbook/worksheet *

Never

Sometimes

Often

Always

Comments

Area of Language

Is Understanding of Language an area of concern? *

Yes

Area of Language

Understanding of Language

Has difficulty understanding spoken instructions/information *

Never

Sometimes

Often

Always

Comments

Area of Language

Understanding of Language

Require repetition of spoken instructions/information *

Never

Sometimes

Often

Always

Comments

Area of Language

Understanding of Language

Require simplification of spoken instructions/information e.g. one instruction at a time *

Never

Sometimes

Often

Always

Comments

Area of Language

Understanding of Language

Has trouble understanding the meaning of words *

Never

Sometimes

Often

Always

Comments

Area of Language

Understanding of Language

Has trouble with understanding new ideas, topics, information *

Never

Sometimes

Often

Always

Comments

Area of Language

Understanding of Language

Has trouble with recalling information e.g. information learnt in class or throughout the school day, experiences during breaks, personal experiences such as weekends, before and after school *

Never

Sometimes

Often

Always

Comments

Area of Language

Understanding of Language

Has difficulty answering comprehension questions e.g. based on a text and or paragraph *

Never

Sometimes

Often

Always

Comments

Area of Language

Understanding of Language

Has difficulty makes inferences e.g. making predictions, providing justifications for their answers, identifying subtle clues *

Never

Sometimes

Often

Always

Comments

Area of Language

Is Expressive Language an area of concern? *

Yes

Area of Language

Expressive Language

Has trouble expressing their thoughts *

Never

Sometimes

Often

Always

Comments

Area of Language

Expressive Language

Has trouble describing things *

Never

Sometimes

Often

Always

Comments

Area of Language

Expressive Language

Has trouble finding the right words *

Never

Sometimes

Often

Always

Comments

Area of Language

Expressive Language

Has trouble using a variety of vocabulary of words when talking (e.g. only uses simple vocabulary *

Never

Sometimes

Often

Always

Comments

Area of Language

Expressive Language

Has trouble getting to the point when talking *

Never

Sometimes

Often

Always

Comments

Area of Language

Expressive Language

Has trouble putting events in the right order when telling stories or talking about things that happened. *

Never

Sometimes

Often

Always

Comments

Area of Language

Expressive Language

Has poor grammar when talking *

Never

Sometimes

Often

Always

Comments

Area of Language

Expressive Language

Talks in short, disjointed sentences *

Never

Sometimes

Often

Always

Comments

Area of Language

Expressive Language

Has trouble using complete sentences when talking *

Never

Sometimes

Often

Always

Comments

Area of Language

Expressive Language

Has trouble expanding an answer or providing details *

Never

Sometimes

Often

Always

Comments

Area of Language

Expressive Language

Has trouble saying something another way when someone does not understand *

Never

Sometimes

Often

Always

Comments

Area of Language

Expressive Language

Has a negative reaction when people do not understand them e.g. frustration, upset *

Never

Sometimes

Often

Always

Comments

Area of Language

Is Social Skills an area of concern? *

Yes

Area of Language

Social Skills

Has difficulty expressing their needs and wants, making requests *

Never

Sometimes

Often

Always

Comments

Area of Language

Social Skills

Has difficulty asking for clarification, repetition, support *

Never

Sometimes

Often

Always

Comments

Area of Language

Social Skills

Has difficulty initiating/maintaining conversation with peers *

Never

Sometimes

Often

Always

Comments

Area of Language

Social Skills

Has difficulty initiating/maintaining conversation with adults? *

Never

Sometimes

Often

Always

Comments

Area of Language

Social Skills

Has difficulty staying on topic in conversation *

Never

Sometimes

Often

Always

Comments

Area of Language

Social Skills

Has difficulty taking turns in a conversation *

Never

Sometimes

Often

Always

Comments

Area of Language

Social Skills

Has difficulty appropriate eye contact during conversation *

Never

Sometimes

Often

Always

Comments

Area of Language

Social Skills

Has difficulty using body language e.g. gestures, facial expression, body movements, head movements *

Never

Sometimes

Often

Always

Comments

Area of Language

Social Skills

Has difficulty understanding body language e.g. gestures, facial expression, body movements, head movements *

Never

Sometimes

Often

Always

Comments

Area of Language

Is Speech Sounds an area of concern? *

Yes

Area of Language

Speech Sounds

Difficult to understand? *

Never

Sometimes

Often

Always

Comments

Area of Language

Speech Sounds

Has difficulty with producing speech sounds? If so, which sounds? *

Never

Sometimes

Often

Always

Comments

Area of Language

Is Voice an area of concern? *

Yes

Area of Language

Voice

Difficult with voice? E.g. voice hoarseness, husky? *

Never

Sometimes

Often

Always

Comments *

Area of Language

Voice

Low volume? *

Never

Sometimes

Often

Always

Comments *

Any additional comments? *

What strategies do you currently have in place? *

UL Clinic Systems