Child Intake Form
Date Of Birth
Diagnosis (If Known)
City , State , Zip
Emergency Contact Name
Emergency Contact Relationship to Child
Emergency Contact (Information)
Physician Phone Number
Other Physicians / Specialists Involved In Care
Secondary Physician Number
Secondary Physician Address
How did you hear about [Private Practice / Private Practitioner Name?
Parent 1 Name
Parent 2 Name
What adults does the child live with? Check all that apply
Parent 1 Only
Parent 2 Only
Does the child have siblings or are there other siblings in the home?
Child 1 Name
Child 2 Name
Child 3 Name
Child 4 Name
Child 5 Name
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?
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?
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?
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?
2. Was there any stress during the pregnancy?
3. Were there any complications during labor or delivery?
4. What was the mother’s age at the time of delivery?
1. How many weeks gestation was the child born? (40 weeks is typical)
2.At the time of Birth Child was?
3. How was the child delivered?
4. Please describe any complications or concerns during labor or delivery
Check and describe all that apply
Traumatic brain injury
Is the child up to date with immunizations
Has the child ever had surgery?
Has the child ever been hospitalized
Has the child ever been in a serious accident?
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
Does the child have any known allergies?
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?
Does the child have any known hearing loss?
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
Psychologist / Psychiatrist
At what age did the child do the following
Understood by Other
Does the child do any of the following
Choke on liquids
Choke on foods
Maintain a special diet
Use a pacifier / suck thumb
Please describe any of the above
If under 4 years of age, how many words does the child say
Does the child produce sentences of the following length
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
Answering simple questions
Producing speech sounds
Chewing or eating
Maintaining eye contact
Please describe any of the above
Has the child experienced any difficulty with feeding or swallowing? If so, please describe
Is the child currently enrolled in daycare/ school:
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
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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