This survey helps us learn about your child’s language background, communication preferences, and language development needs. Your responses will help us better support your child and communicate with your family.
Child Information
- Child’s Name
- Birthdate
- Gender
- Child’s Age
- Parent’s Name
- Parent’s Phone
- Parent’s Email
Question #1
How does your child currently communicate? (check all that apply):
- Babbling/baby sounds
- Gestures (like pointing to what they want, or shaking head for “no”)
- Sign language/baby signs
- Short phrases
- Sentences
Question #2
If your child is able to talk, can you understand what they are saying? (check one):
- Yes
- No
- Sometimes
Question #3
Is your child receiving speech therapy to help them with their language skills?
- Yes
- No
- In the past
If yes, please describe:
Language Questions
If your child hears or is learning to speak any language(s) other than English at home, please complete the rest of this survey.
What language(s) do family members (other than this child) speak at home?
| Name | Relationship to Child | Language(s) |
| Name | Relationship to Child | Language(s) |
| Name | Relationship to Child | Language(s) |
| Name | Relationship to Child | Language(s) |
What language(s) does your child understand best?
If your child has started to talk, what language(s) does your child speak most often?
What language(s) do you feel most comfortable speaking?
What language(s) do you prefer to receive written information in?
If translation of a written form or handout in your preferred language is not immediately available, is there an adult in your home who can read and understand English?
- Yes
- No
- Sometimes
Would you be willing to teach us some words in your home language(s) that will help us communicate with your child? If yes, please let us know how best to reach you.
This document was last modified on: September 15, 2026