Speech-Language Initiative

Read-Along Songs Family Set Application Form

Please complete for each family you wish to give a set of Read-Along Songs to keep. All fields are required.

Therapist Name:
SLP Initial code for family:	(e.g. SLP Initials, #)
Age of the child receiving Speech/Language services:
Number of adults:
Number of children:
Family make-up:	(e.g. 2 parent home, single parent family, teen parent, multigenerational home)
Please share any pertinent information regarding why you want to give this family Read-Along Songs to keep.
Please determine the following based on your observations, prior knowledge of, or phone interview with the family. For Family Reading Partnership data collection purposes only.
This family is resource challenged:	Yes    No
This child is at-risk due to speech/language/cognitive delays:	Yes    No
Number of children's books in the home:	0 -10 11-20 21 + Comments:
Other materials in the home that adults read (e.g. newspapers, magazines, books)	none (0) few (1-5) many (6+)
Adults read to the child in the home:	0-2 times per week 3-4 times per week 5-7 times per week Multiple times daily Other:
I have discussed the benefits of spending time reading and listening to Read-Along Songs together with the child's family.	Yes    No

If you have any questions, please contact Lisa Berry by phone at 607-277-8602 or via email at lisa@familyreading.org.