CHILDHOOD STUTTERING: REFERRAL INDICATOR FOR PARENTS, TEACHERS & PHYSICIANS*

Instructions: Please answer following questions:

I. Risk Factors:

1.1.	Has the problem persisted longer than 6 months?	Yes No
1.2.	Is there a history of stuttering in the family?	Yes No
1.3.	Are there parental concerns?	Yes No
1.4.	Are the cycles of stuttering longer than the cycles of fluency?	Yes No
1.5.	Does the child seem aware, concerned or frustrated with the stuttering?	Yes No

II. Speech Behaviors:

2.1.	Does the child repeat or prolong parts of words?	Yes No
2.2.	Does the child appear to strain or struggle while trying to speak?	Yes No
2.3.	Does the child stop talking because it is too hard?	Yes No
2.4.	Are there any physical behaviors associated with stuttering (i.e., loss of eye contact, hand, arm, leg or body movements)?	Yes No
2.5.	Is the child's speech fragmented, disrupted or tense?	Yes No

If two or more questions are checked, please contact a speech pathologist with expertise in fluency for consultation or evaluation.

For referral information, contact the Stuttering Foundation of America at 1-800-992-9392 or contact the Center of Stuttering Therapy

Parent's name		Date
Address		Phone
City and Zip		e-mail address
Child's name		Child's age

or print out & fax to: 303-527-0756 (Please call first 303-530-9191)
or mail to CST

* Developed by Wallace, M.L. and Walton, P.O., Center for Stuttering Therapy
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