Speech Therapy Intake Form for Communication Works

Speech Therapy Application Form

Contact Information

Personal Information

Child resides with:	Child has contact with but doesn't live with:
Biological Mother	Biological Mother
Biological Father	Biological Father
Adoptive Mother	Adoptive Mother
Adoptive Father	Adoptive Father
Foster Mother	Foster Mother
Foster Father	Foster Father
Other (specify)	Other (specify)

If custodial parents are separated, please describe current timeshare:
What are your major concerns regarding your child?
Have you consulted other professionals regarding these concerns?		YES NO
If yes, please list any other professionals (i.e. Pediatrician, Neuropsychologist, learning specialist):

Birth History

Pregnancy:	Normal	Complications - briefly explain:
Labor:	Normal	Complications - briefly explain:
Birth Weight:	Lbs oz.	Apgar Scores: (if remembered)
Post-Delivery:	Normal	Complications - briefly explain:
	Weak Suck	Vomiting Diarrhea Low Tone Infections
Number of days baby was in hospital after delivery:

Medical History

Check all that apply
Chronic Colds/respiratory infections	Temporary Hearing Loss	Asthma
Chronic Ear Infections	Hearing Impairment	Alergies
Cerebral Palsy	Attention Deficit Disorder	Tonsillitis
Head Trauma	Eye Problems
Previously diagnosed global developmental delay	High Fever

Other serious illness or condition (please describe):
Hospitalizations for illness or operations (please describe)
What medication(s) is your child taking (please indicate the name and dose):
Please list any allergies your child has:

Development
At what age did you first become concerned about your child's speech, and why?

Birth to Two Years
Please check all of the following that applied to your child during their first two years.
Separation from parents for a long time			Avoidance of eye contact
Frequent hospitalization			Nonresponsive when spoken to
Resistance to cuddling			Unusual play methods
Difficult to calm			Failure to develop gestures (bye-bye)
Colicky			Failure to point or request
Restless			Failure to coo or babble
Inactive			Difficulty sharing
Difficutly eating			Difficulty sleeping
Accident prone

What was the *approximate* age that your child...
	Pointed (joint attention):
	Smiled:
	Sat without support:
	Crawled:
	Walked with assistance:
	Spoke first words:
	Spoke in phrases:
	Spoke in sentences:
	Self fed using finger food:
	Self fed using cup/spoon:
	Potty trained/by day:
	Dressed self:

Does you child (please check all that apply):
Repeat sounds, words, or phrases over and over			Understanding what you are saying
Respond correctly to who/what/when questions			Follow simple directions
Retrieve/point to common objects when requested			Respond correctly to Yes/No questions

How does your child currently communicate?
Body language	Sounds (vowels, gurgling)	Words (shoe, doggy)
2 to 4 word sentences	Sentences longer than 4 words	Other (please explain)

Feeding Issues
Does you child currently have any problems with drinking liquid or eating various textures that result in any of the following:
Choking	Vomiting after eating	Gagging
Difficulty eating certain textures	Taking more than 30 min to eat	Currently see feeding specialist

Sensory Issues
Do you have any concerns about your child's sensory processing skills? (i.e. sensitivity to loud sounds, touch, taste, or smell, toe walking, etc.)				No Yes - briefly explain:

Comprehension
Do you believe that your child understands and requests as well as other children his/her age?				Yes No - briefly explain:

Educational History

Please list all schools attended beginning with preschool

Current School:		Class Size:
Special Education Services (if any):

Social History

Please describe any behavioral concerns at home or in school:
Peer Relationships
Does you child seek friendship with peers?		Yes No
Is your child sought by peers for friendship?		Yes No
Does your child play primarily with children his/her own age		Yes No
		If no, Younger Older
Briefly describe any problems/concerns you have regarding your child's peer relationships:

Interests/Hobbies
What does your child like to do in their free time?
Siblings
Name	Age	Medical/Social/Academic Concerns
Name	Age	Medical/Social/Academic Concerns
Name	Age	Medical/Social/Academic Concerns

Please provide any further information you feel would be helpful regarding your child.

Client Availability
Please indicate by "X" which time and date slots your child is NOT available to attend a speech therapy.
	Monday	Tuesday	Wednesday	Thursday	Friday
10:00-10:30am
10:30-11:00am
11:00-11:30am
11:30-12:00pm
12:00-12:30pm
12:30-1:00pm
1:00-1:30pm
1:30-2:00pm
2:00-2:30pm
2:30-3:00pm
3:00-3:30pm
3:30-4:00pm
4:00-4:30pm
4:30-5:00pm
5:00-5:30pm
5:30-6:00pm
6:00-6:30pm
6:30-7:00pm