Portland State University Functional Communication Parent Questionnaire 2014-2025 free printable template

Functional Communication Parent Questionnaire Portland State University Angela Wilson Christina Gildersleeve-Neumann Child s name Date of birth Filled out by Date filled out This questionnaire captures your child s current communication needs to create immediate functional treatment goals. Purpose and goals for children with speech sound disorders. The information provided by caregivers can help create a therapy program that is individualized and meaningful to children and that incorporates...caregiver s ideas in the construction of motivating speech goals. Instructions Please read each question and provide answers to the ones that apply to your child. As you answer the questions think of the words and phrases that your child communicates as they say it. For example if your child says mommy rather than mom please write down mommy. This questionnaire is designed to explore your child s language use so that meaningful words can be chosen for individualized therapy. For many of the...questions we have included example words and phrases in parenthesis. If your child uses a means of communication other than verbal words to convey a message for example pointing signing facial expressions please include that information* child s communication* It is long and you may choose to skip sections that you feel are not important for your child at this time. Below are the section names and the corresponding page numbers for the questionnaire. Names p* 2 Activities p* 3 Places p* 4...Requests and Needs p* 4-5 Emotions and Feelings p* 5-6 Toys and Materials p* 6 Food and Drink p* 7 Household Items and Places p* 7 Clothing p* 8 Question Words p* 8 Yes and No Responses p* 8 Social p* 9 Other words blank page p* 10 As you go or when you finish please mark with a star the 10 20 50 words that you believe are most meaningful to your child. These may be the words that are targeted first in treatment. Names Think about the names and the words that your child and your family uses when...communicating about people pets toys and characters. If it is not clear please indicate the relationship of the name to your child e*g* Alex brother Michelle friend at school Erick physical therapist. Family Members What specific names and/or words does your child use when communicating about family members e*g* mom mama daddy Alex brother Uncle John. Teachers and Other Professionals about and what are their roles e*g* Erick physical therapist karate teacher. Friends What specific friends does...your child like to communicate about Please write down the names your child would use consider nicknames. Pets and Animals What are the specific names of pets or other animals that are important to your child Please indicate the types of animals e*g* Jordan dog pet at home. Please list any names that your child would like to communicate about or that you would like her to communicate about. What activities does your child enjoy doing at home e*g* drawing puzzles dress up watching movies. What...are some other activities that your child participates in These could be community activities or social activities e*g* swim class cooking with mom going to a specific person s house.