Child's Name:
*
First Name
Last Name
DOB:
*
MM
DD
YYYY
Gender:
*
Select
Male
Female
Home Address:
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Home Phone (if available)
*
(###)
###
####
Form completed by:
*
Select
Mother
Father
Guardian
Parent / Guardian 1:
*
First Name
Last Name
Occupation
Address (if different)
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Cell Phone:
(###)
###
####
Work Phone:
(###)
###
####
Email Address
*
Parent / Guardian 2:
Occupation
Parent / Guardian 2 Cell Phone:
(###)
###
####
Siblings Name(s) and Age(s), if any:
Primary language spoken at home:
Any other languages spoken at home:
Describe your child's strengths:
Describe your concerns about your child's communication skills:
Is there any family history of a speech or language disorder? If yes, please explain:
When did you first become concerned about your child’s communication skills?
Has your child ever had a speech and language evaluation in the past?
Select
No
Yes
If yes, please explain:
Has your child ever received speech and language therapy in the past?
Select
No
Yes
If yes, please provide dates and agency:
Has your child ever received any other therapies (e.g. OT, PT)?
Select
No
Yes
If yes, please provide type, dates, and agency:
At what age did your child babble (i.e. da, ba)
At what age did your child say first word?
At what age did your child put two words together?
At what age did your child put 3 words together?
At what age did your child use complete sentences?
Does your child follow one-step directions (ex: “put your shoes on”)?
Select
No
Yes
Does your child follow two-step directions (ex: “get your cup and put it in the sink”)?
Select
No
Yes
Does your child point to common objects upon request (ex: shoe, ball, door)?
Select
No
Yes
Does your child answer yes/no questions?
Select
No
Yes
Does your child name a variety of common objects (ex: car, ball, apple, dog, hat)?
Select
No
Yes
Does your child speak clearly so that others may understand him/her?
Select
No
Yes
Does your child understand what you are saying?
Select
No
Yes
Does your child repeat words, sounds, phrases over and over?
Select
No
Yes
Does your child participate in conversations with peers and adults?
Select
No
Yes
Does your child answer simple who, what, where questions?
Select
No
Yes
Please state what you would like for your child to learn from speech therapy services:
Describe mother's health during pregnancy:
Child's birth weight:
Premature birth?
Select
No
Yes
Weeks Gestation?
Please describe any complications before, during, or after birth:
Does your child have a specific diagnosis at this time? (e.g. Autism, ADHD, etc)
Select
No
Yes
If yes, please state diagnosis, date diagnosed, and by whom.
At what age did your child roll over?
At what age did your child sit?
At what age did your child crawl?
At what age did your child walk?
At what age did your child walk up/down stairs?
At what age did your child feed self?
At what age did your child dress self?
At what age did your child use the toilet?
Please explain any concerns you have about your child's development OTHER THAN speech and language skills (if any).
Please list any surgeries, major illnesses, or hospitalizations since birth:
If your child is currently taking any medications, please list them here:
Does your child use a pacifier or suck thumb or fingers? If yes, please explain.
What type of cup does your child drink from? (E.g. Bottle, valve sippy cup, straw sippy cup, regular open cup, etc)
Does your child have a history of ear infections?
Select
No
Yes
If yes, please state how many, age of first occurrence, and date of last occurence.
Has your child ever had pressure equalizing tubes (PE tubes) inserted?
If yes, please state when they were inserted, whether both ears or one, and whether they are currently still in place.
Has your child's vision or hearing been screened or tested?
Select
No
Yes
If yes, please state results:
If you have any concerns about your child's behavior at school, please describe here:
Today's Date
MM
DD
YYYY