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Tag
Blurb
Home
About
About Speakeasy
About Alexandra
Services
Getting Started
Evaluations
Individual Speech/Feeding Therapy
Group Therapy
Reading
PDD/AUTISM
Parent Groups
Scheduling
Resources
Contact
Blog
Intake Form
CLIENT HISTORY
(Please bring copies of related evaluations and/or current IEP’s to your first appointment.)
Date
*
today's date
MM
DD
YYYY
Child's Name
*
Child's Sex
*
Child's Age
*
Child's Birthdate
*
MM
DD
YYYY
Parent's Name
*
Parent's Phone
*
(###)
###
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Parent's Name
Parent's Phone
(###)
###
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Home Address
*
Who is filling out this questionnaire?
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What are your concerns regarding your child’s speech and/or language?
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When did you first notice the issue(s)?
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Do you feel that your child’s speech and/or language is different than children his or her own age? If so, how?
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Who have you seen regarding these issues?
*
Has your child ever received a speech language evaluation? When? How has this issue changed since you first noticed it?
*
FAMILY INFORMATION
Language(s) spoken in the home
*
Parent's occupation
*
Parent's level of education
*
Siblings: Names & Ages
Are there any family members or relatives who have or had received any kind of Special Education Services? Explain.
*
Are there any family members or relatives who have or had any speech, language, or hearing issues or therapy? Explain.
*
Pregnancy, Birth History and Early Development
During pregnancy with this child, did mother have any illnesses? If so, what?
*
Was labor at all problematic? If so, explain:
*
Was the child’s birth at all problematic? If so, explain:
*
Type of Delivery
*
Vaginal
Caesarian
Was feeding a problem? If so explain.
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Is he/she a picky eater? If yes, please explain.
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Does your child eat:
*
Pureed foods
Yogurt/Pudding
Crunchy foods
Cookies/Pretzels
Was your child very active as a baby?
*
When did your child first learn to:
crawl
*
self feed
*
walk independently
*
Is your child clumsy?
*
If your child has difficulties with any of the above or any other motor activities, please explain:
Medical History
Pediatrician’s name
*
Pediatrician’s Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Pediatrician’s Phone
*
(###)
###
####
Has your child ever been hospitalized? Age and reason:
*
Has your child ever had any serious illnesses or accidents? Explain Has your child ever fainted? Had seizures?
*
Does your child have problems hearing? Ear Infections? If so, how many?
*
Last hearing exam date and results:
*
Has your child had middle ear tubes inserted?
*
Did your child have his/her tonsils/adenoids removed? If so, when?:
*
Does your child have any problems seeing? Wear glasses?
*
Does your child have any trouble sleeping at night? Explain:
*
What medications if any is your child on?
*
Is your child presently being treated by a pediatrician? Psychologist? Therapist? Neurologist? Physical Therapist? Occupational Therapist? ENT?
*
(please provide name and contact information)
Speech History
Was your child very quiet as a baby?
*
yes
no
did he/she Babble?
*
yes
no
When did your child speak single words (other than “mama” or “dada”)?
*
When did your child begin to combine words (two words)?
*
Does your child use speech consistently to communicate? Frequently? Occasionally? Never?
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Does your child use gestures to communicate?
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How does your child primarily communicate? Explain
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(provide 3 examples of your child’s best communication)
If your child talks now, can you understand? Can family members? Can strangers?
*
Does your child answer questions?
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yes
no
Does your child follow directions?
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yes
no
Educational/Social History
Where does your child attend school?
*
What grade?
*
Has your child had any problems in school?
*
Is your child able to make friends?
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Has your child’s teachers had any complaints about your child’s behavior, learning, or social development? If so, explain:
*
Has your child’s teachers had any complaints about your child’s behavior, learning, or social development? If so, explain:
*
Please state any additional information or comments you feel would be helpful to me in evaluating your child’s speech/language behavior:
*
Reading and Writing
if age appropriate please complete
Has your child had any problems learning to read? Learning to write? Explain:
*
Thank you!
