Child Intake Form

Today's Date

Client Name

Nickname

Date Of Birth

Age

Gender

Male Female

Diagnosis (If Known)

Address

City , State , Zip

Phone #1

Cell Home Work Other

Phone #2

Cell Home Work Other

Email #1

Email #2

Emergency Contact Name

Emergency Contact Relationship to Child

Emergency Contact (Information)

Marital Status

Single Married Divorced Widowed

Client’s Physician

Physician Phone Number

Physician Address

Other Physicians / Specialists Involved In Care

Referring Physician

Phone Number

Physician Address

Secondary Physician

Secondary Physician Number

Secondary Physician Address

How did you hear about [Private Practice / Private Practitioner Name?

Family Background

Parent 1 Name

Age

Occupation

Education Level

Parent 2 Name

Age

Occupation

Education Level

Marital Status

Single Married Divorced Separated Widowed

What adults does the child live with? Check all that apply

Birth Parent(s) Adoptive Parent(s) Foster Parent(s) Grandparent(s) Both Parents Parent 1 Only Parent 2 Only Other

Does the child have siblings or are there other siblings in the home?

Child 1 Name

Age

Sex

Speech Issues

Child 2 Name

Age

Sex

Speech Issues

Child 3 Name

Age

Sex

Speech Issues

Child 4 Name

Age

Sex

Speech Issues

Child 5 Name

Age

Sex

Speech Issues

Language(s) spoken in the home

Who speaks the other language(s)?

Describe the child’s use/understanding of the language(s)

Is there anything additional you would like to share about the family / home environment?

Evaluation

Briefly describe why you’re seeking an evaluation by a speech-language pathologist at this time

What are you expecting out of this evaluation / meeting?

Has the child had a previous speech, language or feeding evaluation / treatment?

Yes No

By Whom

When

Describe the results

Describe in your own words the nature of your concerns about the child’s development and/or the primary referral reasons

At what age did you first notice the problem?

How do the child’s communication difficulties impact the family?

If anyone else in the family has a speech or language diagnosis, please describe it

Is the child aware of or frustrated by their communication difficulties?

Medical History

Describe any pertinent information about the child’s medical history (surgeries, diagnoses, etc.) as well as when they were diagnosed and by whom

Mother’s Health During Pregnancy

1. Were there any infections or illnesses?

Yes No

Describe

2. Was there any stress during the pregnancy?

Yes No

Describe

3. Were there any complications during labor or delivery?

Yes No

Describe

4. What was the mother’s age at the time of delivery?

Child’s Health

1. How many weeks gestation was the child born? (40 weeks is typical)

2.At the time of Birth Child was?

Lbs

Oz

Inches

3. How was the child delivered?

Vaginally Cesarean Section

4. Please describe any complications or concerns during labor or delivery

Check and describe all that apply

Adenoidectomy Asthma Behavior Issues Brain injury Breathing problems Cardiac issues Chicken pox Diabetes Ear infections Ear tubes Encephalitis Frequent colds High fever Measles Meningitis Mumps Seizures Sensory issues Sleep issues Tongue tie Tonsillitis Tonsillectomy Traumatic brain injury Vision issues

Describe

Is the child up to date with immunizations

Yes No

Please describe

Has the child ever had surgery?

Yes No

Please describe

Has the child ever been hospitalized

Yes No

Please describe

Has the child ever been in a serious accident?

Yes No

Please describe

Does the child have a chronic illness? If so, please describe

Is the child currently on any medications? If so, please list medication name and reason for medication

Medication 1

Medication 2

Medication 3

Medication 4

Does the child have any known allergies?

Yes No

Describe

Does the child currently use any equipment? (communication device, walker, etc.) Describe

Does the child have a history of ear infections, tubes, etc. or use hearing aides?

Yes No

Describe

Does the child have any known hearing loss?

Yes No

Describe

If you have any concerns about the child’s hearing, please describe:

Describe the child’s current health status

Is the child currently receiving any of the following services? If yes, please list the person’s name and last date of service

Developmental Pediatrician Neurologist PT OT SLP Behavioral Therapist Educational Consultant Psychologist / Psychiatrist Vision Therapist Other

Developmental History

At what age did the child do the following

Sit alone

Crawl

Stood Up

Walk

Made Sounds

First Word

Combined Words

Sentences

Fed Self

Understood by Other

Dressed Self

Toilet Trained

Does the child do any of the following

Choke on liquids Choke on foods Avoid foods Maintain a special diet Use a pacifier / suck thumb Mouth objects

Please describe any of the above

If under 4 years of age, how many words does the child say

0-20 21-50 51-100 101-150 151-300 301-500 501+

Does the child produce sentences of the following length

2 words 3 words 4 words 5+ words

What percentage of the child’s speech do you understand? (%)

How well do people outside of the family understand their speech? (%)

If the child is not using words, how do they communicate?

Does the child have any difficulty with the following

Attention Aggression Answering simple questions Understanding people Excessive drooling Producing speech sounds Reading Remembering Transitions Frustration Tolerance Anger Answering questions Following directions Chewing or eating Stuttering School work Maintaining eye contact Word Retrieval Other difficulties

Please describe any of the above

Has the child experienced any difficulty with feeding or swallowing? If so, please describe

Educational History

Is the child currently enrolled in daycare/ school:

Yes No

What is the name of the program?

What day(s) do they attend?

What is their grade level

Type of classroom

If they receive any accommodations, please describe

Please describe any educational difficulties or learning challenges that this child has faced

Social History

Describe how the child interacts with parents, siblings, or other family members

Please describe the communication difficulties the child faces in the home environment

Describe any significant events or changes within the home

What are the child’s strengths?

What are the child’s weaknesses?

What are the child’s favorite activities?

Does the child participate in any community activities (ex. play groups, sports, etc.) and how is their communication / behavior?

Does the child become easily frustrated with certain activities? If so, please explain

Describe how the child interacts with other children

What are your goals for the child over the next 6 months?

What are your goals for the child over the next 5 years?

Is there anything else that is important for us to know about the child?

Person filling out the form

Relationship to the child

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