CHILD INTAKE FORM SPEECH

  • Child's Information

  • MM slash DD slash YYYY
  • Include when the problem was first noticed, who noticed it, and where the problem occurs.
  • Type of ServiceDates/Age of ChildName 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.
    Check all that apply.
  • NameAgeRelation to the Child 
    For each additional person, click the "plus" to the right to create another row.
  • Answer yes or no. If yes, please indicate name & type.
  • Parent Information

  • MM slash DD slash YYYY
  • If not applicable, type N/A.
  • If not applicable, type N/A.
  • MM slash DD slash YYYY
  • If not applicable, type N/A.
  • (If not applicable, type N/A.)
  • Relation to childDiagnosis/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

    Check all that apply.
  • If not applicable, type N/A.
  • If not applicable, type N/A.
  • If not applicable, type N/A.
  • If not applicable, type N/A.
  • Child's Feeding Development

    Check all that apply.
  • Sippy CupOpen CupStrawUtensils
    If not applicable, type N/A.
  • If not applicable, type N/A.
  • If not applicable, type N/A.
  • Child's Speech & Language Development

  • Babbling (bababa)Jargon (bada bama)First word (age & word)Two-word combo (more milk)Three-word comboSentences
    Give your best estimate for each. If not applicable, type N/A.
  • Reading lettersWriting lettersReading wordsWriting words
    Give your best estimate for each. If not applicable, type N/A.
  • Reading sentencesWriting sentences
    Give your best estimate for each. If not applicable, type N/A.
  • If child never used a pacifier, type N/A.
  • If child never sucked thumb/fingers, type N/A.
  • Parent(s)Sibling(s)Peer(s)Teacher(s)Extended familyStrangers
    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
  • Child's Strengths & Favorites

  • Additional Forms

  • 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

    • MM slash DD slash YYYY