Speech Therapy Intake Form "*" indicates required fields Step 1 of 5 20% Child's Name* First Last Does the child have a nickname?Child's Date of Birth* Month Day Year Parent InformationParent Name* First Last Parent Phone Number*Parent Email Address* Are there other languages spoken at home? If yes, which language(s), how often & with whom?*Tell Us What Brought You HereWhich of your child's speech-language skill deficits led you to seek intervention from a speech-language pathologist?* Speech - problems with spoken language, including the formation of sound, nature of sound quality, clarity, etc. Fluency - difficulty with the smoothness with which sounds, syllables, words, and phrases are joined together during speech; Example: stuttering Voice - issues with voice quality, pitch, and loudness Language/Expressive - difficulty communicating their own thoughts/feelings through spoken words, gestures, signs, or symbols Language/Receptive - trouble understanding and comprehending the spoken language of others) Social Communication - struggles to effectively communicate/interact with others - verbally or non-verbally Behavior - often intertwined with speech-language delays/disorders Check all that apply.In your own words, describe the concerns you have about your child's communication skills. Include when the concerns first arose, where issues most often occur or are most noticeable, and how they impact your child's daily life.*What are your goals for speech therapy? How are you hoping speech-language therapy will help your child?*Do any other close family members have speech, language or related difficulties/disorders (i.e., autism, ADHD, dyslexia, etc.).*Relation to childDiagnosis/Diagnoses Add RemoveFor each additional relative with relevant diagnoses, click the "+" symbol to create another entry. If none, enter "None" in the first column/row. Child's Feeding DevelopmentChild was: Breastfed. Formula fed. Bottle fed. NG feeding tube. Select AllCheck all that apply.Describe any difficulties with sucking, swallowing, chewing, eating different textures, etc.*If not applicable, type N/A.List child's favorite foods.*List any food aversions.*If not applicable, type N/A.Child used a pacifier from _ months to _ months of age.*If child never used a pacifier, type N/A. Child sucked thumb/finger from _ months to _ months of age.*If child never sucked thumb/fingers, type N/A. Speech & Language SkillsWho understands your child's speech, and how much do they understand? Give your best guess of a percentage value for each: 25% = 1 out of 4 words understood; 50% = 2 out of 4 words understood; 75% = 3 out of 4 words understood; 100% = 4 out of 4 words understood. Write N/A if not applicable.*Parent(s)Sibling(s)Peer(s)Teacher(s)Extended familyStrangersDoes your child currently receive speech-language therapy services at school?* Yes No Not applicable If your child DOES receive speech-language therapy services at school, please tell us about them (for how long, daily/weekly frequency, primary goals, how it's going, etc.)How does your child react to being misunderstood or unable to communicate?* Tries again/revises Gets angry/frustrated Gives up Doesn't notice This is not a problem Other (please specify in the next question) Is your child aware of their communication difficulties?* Yes. No. I'm not sure. Do you wish to share information with your child, such as goals or diagnosis?* Child's Strengths & FavoritesDescribe your child’s strongest skills and personality traits. What makes your child special, interesting, and awesome?*What are your child's favorite activities, hobbies, toys, movies, shows, characters, games, etc.?Does your child have any strong sensory aversions?*Tell us what days, times, and location would be ideal for Speech Therapy. (Ex: Anytime Monday-Thursday, 8a-3p, in-clinic/at home, etc.)*While we cannot guarantee our availability will match your desired schedule exactly, we'll do our best! How did you learn about us?* Online search Social media Brochure, flier, business card or other printed media Recommended by a friend or family member Referred by a physician or other healthcare provider Online ad Other If you answered "other" to the previous question, please describe:Clinical DocumentationIf you have additional clinical or educational documentation pertaining to your child's diagnosis, treatment, or education that would be relevant to their speech therapist and that you did NOT already upload on the main Intake Form for All New Patients, please upload here. Drop files here or Select files Accepted file types: jpg, pdf, Max. file size: 195 MB. Parent/Guardian SignatureParent electronic signature* First Last By providing this electronic signature, I hereby affirm I am the parent/guardian of the aforementioned child, for whom I am legally authorized to make medical decisions. I agree to each of the above conditions as indicated, and certify all information contained in this form is complete and accurate to the best of my knowledge. I understand that an electronic signature is the legal equivalent of my manual/handwritten signature, and I am agreeing to all terms and conditions as indicated in this form.Today's Date* Month Day Year Δ
