First Name * Last Name * Email Address * Phone Number * 1: My child spoke his first word after the age of two years * Yes No 2: His/her brother or sister has received speech therapy * Yes No 3: My child is often difficult for others to understand * Yes No 4: My child has difficulty following simple directions * Yes No 5: My preschool child speaks in word/phrases rather than sentences * Yes No 6: My child does not play well with other children * Yes No 7: My child has difficulty talking about a story or event * Yes No 8: My child has difficulty answering questions with detail * Yes No 9: My child has a difficult time staying focused in play * Yes No 10: My child is currently being treated for a medical disorder * Yes No * *If you answered “yes” to 2 or more questions, your child may be at risk for a speech-language disorder. Please contact the Midland County Educational Service Agency via the link provided and a representative will respond to you regarding the need for a referral for a free speech-language evaluation.