Eden ABA Therapy

Compassionate autism care

Eden ABA Therapy · Intake Screening

Speech & Language Therapy Screening Form

Share your family's concerns so Eden's intake team can review screening information and help determine appropriate next steps. This form does not diagnose and does not replace evaluation by a licensed Speech-Language Pathologist.

Child Information

Parent / Guardian Information

Contact Information

Primary Concerns

Speech & Language Questions

Scoring: No = 0, Sometimes = 1, Often = 2. This screening is not a diagnosis.

Understanding Language

Difficulty following simple directions?
Difficulty understanding questions, routines, or daily instructions?

Expressive Language

Uses fewer words or shorter phrases than expected?
Frustration, crying, or behavior because communication is hard?

Speech Clarity

Unfamiliar people have trouble understanding your child?
Leaves off sounds, substitutes sounds, or speaks unclearly?

Social Communication Questions

Difficulty with conversation, turn-taking, play, or peer interaction?
Difficulty using gestures, shared attention, or communication repair?

AAC Needs

Needs pictures, signs, gestures, or a communication device?

Fluency / Voice Concerns

Repeats sounds/words, gets stuck, or shows stuttering concerns?
Voice sounds hoarse, weak, strained, or unusual?

Feeding / Swallowing Red Flags

Coughing, choking, wet voice, or breathing changes during meals?
Very limited foods, gagging, vomiting, weight concerns, or texture refusal?

Medical & Developmental History

Insurance Information

Consent & Privacy

Information submitted through this form is used only to help Eden coordinate intake and screening follow-up. It is handled with privacy-conscious practices and is not shared for marketing purposes. Submission does not guarantee service approval or insurance authorization.

Disclaimer: This form does not diagnose a speech, language, feeding, or swallowing disorder. Feeding or swallowing safety concerns should be reviewed promptly by qualified medical professionals.

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