Speech Therapy Intake Form

Child's Information

Child's Name*

First Last

Child's Gender*

Male
Female

Child's Date of Birth*

Child's Current Age*

Child's Address*

Street Address Address Line 2 City State ZIP Code

Name of School*

Grade Level*

Name of Primary Care Physician*

Phone Number of Primary Care Physician*

Describe your main concerns.*

Include when the problem was first noticed, who noticed it, and where the problem occurs.

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)

If you answered "other" to the previous question, please specify your child's response.

Why are you seeking speech-language services for your child?*

Has your child’s physician noticed these concerns? If yes, what were his/her recommendations?*

List all other services your child is receiving/has received, including speech therapy, occupational therapy, physical therapy, ABA/behavior therapy, counseling, psychiatric treatment, etc., as well as the dates and the providers.*

Type of Service	Dates/Age of Child	Name of Provider

For each additional service, click the "plus" to the right to create another row. If "none," simply type "none" in the first column/row.

How did you learn about us?*

Recommended by a friend, family member or acquaintance
Recommended by a professional
Google search
Website
Social media (Facebook, Instagram, etc.)
Online ad
Other

If you answered "other" to the previous question or were recommended by an individual, please specify what/who..

With whom does your child live?*

Biological parent(s)
Adoptive parent(s)
Grandparent(s)
Legal guardian(s)
Sibling(s)
Other

Check all that apply.

If you answered "other" to the previous question, please specify with whom the child lives.

List everyone who lives in the same home with your child.*

Name	Age	Relation to the Child

For each additional person, click the "plus" to the right to create another row.

Do you have family pets?*

Answer yes or no. If yes, please indicate name & type.

Parent Information

Parent 1 Name*

First Last

Parent 1 Gender*

Male
Female

Parent 1 Date of Birth*

Parent 1 Address*

Street Address Address Line 2 City State ZIP Code

Parent 1 Primary Phone Number*

Parent 1 Secondary Phone Number

Parent 1 Email Address*

Enter Email Confirm Email

Parent 1 Preferred Method of Contact*

Primary Phone Number
Secondary Phone Number
Email

Parent 1 Place of Employment*

If not applicable, type N/A.

Parent 1 Position at Place of Employment.*

If not applicable, type N/A.

Parent 2 Name

First Last

Parent 2 Gender

Male
Female

Parent 2 Date of Birth

Parent 2 Address

Street Address Address Line 2 City State ZIP Code

Parent 2 Primary Phone

Parent 2 Secondary Phone

Parent 2 Email Address

Enter Email Confirm Email

Preferred Method of Contact

Primary Phone
Secondary Phone
Email

Parent 2 Place of Employment

If not applicable, type N/A.

Parent 2 Position at Employment

(If not applicable, type N/A.)

Are there family circumstances that would be helpful for your child's therapist to know? (Custody arrangements, protection orders, etc.)*

Are there other languages spoken at home? If yes, which language(s), how often & with whom?*

Do any other family members have speech, language or related difficulties/disorders (i.e., autism, ADHD, dyslexia, etc.).*

Relation to child	Diagnosis/Diagnoses

For each additional relative with relevant diagnoses, click the "plus" to the right to create another row. If none, enter "None" in the first column/row.

Child's Health Background

Describe pregnancy with the child, including any complications.*

Describe labor/delivery with the child, including any complications.*

Type of birth (check all that apply).*

Spontaneous (not induced).
Induced.
Vaginal.
C-section.
I'm not sure.

Birth place (hospital/birth center).*

Birth attendant (physician/midwife)

Gestational age (in weeks)*

Birth weight*

Birth length.

Was your child admitted to the NICU?*

Yes
No

If your child was admitted to the NICU, how long was he/she there?

Were there any complications after birth or during the first few weeks?*

Difficulty breathing
Jaundice
Difficulty feeding
Seizures
Birth defects
Birth injury
Other
No complications

Check all that apply.

If your child suffered post-birth complications, please explain.

Has your child's hearing been tested?*

Yes
No

If your child's hearing has been tested, when & where did the testing take place?

If your child's hearing has been tested, what were the results?

Passed.
Did not pass.
Inconclusive.

Describe any serious illnesses, injuries, or medical procedures your child has experienced.*

If not applicable, type N/A.

List any environmental or food allergies.*

If not applicable, type N/A.

List any medications your child is taking or has taken long-term.*

If not applicable, type N/A.

Describe any other conditions or diagnoses identified by your child’s doctor or other professionals.*

If not applicable, type N/A.

Child's Feeding Development

Child was:

Select All
Breastfed.
Formula fed.
Bottle fed.

Check all that apply.

Specify how long (from _ months until _ months) child was breastfed, formula fed and/or bottle fed.*

Indicate at which age your child began using each of the following.*

Sippy Cup	Open Cup	Straw	Utensils

If not applicable, type N/A.

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's Speech & Language Development

At what age (in months/years) did your child begin each of the following?*

Babbling (bababa)	Jargon (bada bama)	First word (age & word)	Two-word combo (more milk)	Three-word combo	Sentences

Give your best estimate for each. If not applicable, type N/A.

At what age (in months/years) did your child begin each of the following?

Reading letters	Writing letters	Reading words	Writing words

Give your best estimate for each. If not applicable, type N/A.

At what age (in months/years) did your child begin each of the following?*

Reading sentences	Writing sentences

Give your best estimate for each. 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.

Who understands your child's speech, and how much do they understand. Give a percentage value for each.*

Parent(s)	Sibling(s)	Peer(s)	Teacher(s)	Extended family	Strangers

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

Has your child's speech/language been evaluated before?*

Yes
No

If your child's speech/language has been evaluated, please note the place and summarize the findings.

What are a few specific goals or skills you would like your child to attain in speech therapy?*

Is your child aware of his/her 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 & Favorites

Describe your child’s strongest skills and personality traits. What makes your child unique?*

Child's favorite activities/hobbies?*

Child's favorite toys?*

Child's favorite movies/shows?*

Child's favorite books.*

Additional Forms

Additional Medical File Attachments

Drop files here or

Accepted file types: jpg, pdf, Max. file size: 195 MB.

Therapy & Wellness Connection requires digital OR paper submission the following documents if available: Speech-language evaluations, hearing tests, recent medical physical and/or relevant medical exams (e.g., autism diagnosis, etc.). Please also submit any existing or prior plans of care (indicating therapy goals) from any other provider of speech, occupational, physical or ABA therapy. Files may be submitted here in .jpg or .pdf format.

Parent/Guardian Signature

Consent*

I agree that all the information entered here is true and current to the best of my knowledge.

Name of Person Who Completed This Form.*

First Last

Relationship to the child:*

Date This Form Was Completed:*

CHILD INTAKE FORM SPEECH

Child's Information

Parent Information

Child's Health Background

Child's Feeding Development

Child's Speech & Language Development

Child's Strengths & Favorites

Additional Forms

Parent/Guardian Signature

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