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Staff
Services
Intake Paperwork & Forms
Locations
Insurance
Careers
- Speech-Language Pathologist
- Center-based BTs-RBTs
Contact Now

Speech Intake Formdevteam@stratedia.com2023-11-28T06:18:58+00:00

ALL TOGETHER LBA PLLC

Pediatric Speech/Language Intake Form

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Name *

First

Last

Date of Birth: *

Sex: *

Male
Female
Other

Age: *

School:

Grade:

Legal Guardian 1: *

Relationship to Legal Guardian 1

Mom
Dad
Other

Please Specify *

Address: *

Phone *

Legal Guardian 2:

Relationship to Legal Guardian 2

Mom
Dad
Other

Please Specify *

Address (If Different):

Phone

Birth History:

Were there any problems during pregnancy and/or birth? *

(If yes, briefly describe) *

Home Environment:

Who lives at home with the child? *

(Siblings (and ages), mother, father, step-parents, grandparents, etc)

How often is English spoken at home? *

Always
Most of the Time
Sometimes
Never

If another language is spoken, what language(s) is/are used in the home?

Any special circumstances?

Parents divorced
Joint physical custody
Child adopted
Other

Please Specify: *

Any cultural or religious considerations for therapy? *

(holiday celebrations, prohibitions, etc)

Health History:

Please Mark Appropriate Box(es) If Your Child Has Had Any of The Following: *

Frequent Ear Infections
Occupational Therapy
Developmental Delay
Early Intervention
Hearing Problems
Physical Therapy
Premature Birth
Tubes In Ears
Speech Therapy
Head Injury
Hospitalization
Behavior Therapy
Allergies (list below)
Prescription Medication (list below)

Please Provide Further Explanations for Items Checked Above: *

Is Your Child Diagnosed with Any Developmental or Sensory Disorders? *

ADHD
Anxiety
Autism
Articulation Disorder
Blind/Visually Impaired
Cerebral Palsy
Deaf/Hard of Hearing
Degenerative Condition
Dyslexia
Down’s Syndrome
Fragile X Syndrome
Intellectual Disability
Language Disorder
Learning Disorder
Opposition Defiance Disorder
Sensory Processing Disorder
Social Communication Disorder
Stuttering
Other (list)

Please Provide Further Explanations for Items Checked Above: *

Do You Suspect Your Child Has Any Undiagnosed Disorders? *

If yes, explain: *

Developmental History:

Please include approximate age of occurrence

First word *

Spoke sentences clearly *

Typical Motor Development? *

Education:

How Is Your Child Currently Educated?: *

Caregiver-led at home
Distance Learning
Pre-school/School

Has Your Child Ever Been Held Back a Grade? *

Which Subjects in School is Your Child on Grade Level for? *

Reading
Math
Science
Social Studies

Does Your Child Receive Special Education Services? *

Does Your Child Have an IEP or IFSP? *

If yes, what is it targeting? *

Communication & Social Interaction

Does Your Child Play Well with Other Children? *

Which of the Following Apply to Your Child? *

Cooperative
Anxious
Hyperactive
Frequent tantrums
Frequent self-stimulation (spinning, hand flapping, etc)
Plays independently with others
Easily frustrated/impulsive
Inappropriate behavior
Minimal eye contact
Poor understanding of danger

Can Your Child Clearly and Appropriately Communicate the Following? *

Statements
Questions
Answers
Wants
Needs (ex: help)
Feelings
Denial/Protests
Discomfort

About How Much of What Your Child Says Can You Understand? *

Almost All
Most
Half
Quarter or Less

About How Much Could a Stranger Understand? *

Almost All
Most
Half
Quarter or Less

Your Thoughts:

Why Do You Think Your Child Has a Communication Delay/Disorder? *

What Have You Already Tried to Remedy the Communication Delay/Disorder? Has it Helped? *

What Is the Main Goal You Wish to Accomplish with Speech/Language Therapy? *

What Methods Do You Consent to Be Utilized for Communication Regarding Your Child? *

Text
Email
Voicemail

PLEASE PRINT YOUR NAME: *

SIGNATURE: *

Clear Signature

Date *

PLEASE INDICATE RELATIONSHIP TO CHILD: *

Parent
Other Legal Guardian

Headquarters
72 West Street
Danbury, CT, 06810
Phone: (845) 202-1056
Fax: (203) 293-9531

New York Offices:

Office #1
27 Howard Street
Norwich, NY 13815
Phone: (845) 202-1056
Fax: (203) 293-9531

Office #2
421 East Main Street, Suite #4
Endicott, NY 13760
Phone: (845) 202-1056
Fax: (203) 293-9531

Outpatient Office:

70 North Street Suite 103,
Danbury, CT 06810
Phone: (845) 202-1056
Fax: (203) 293-9531

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