• NEW CLIENT INFORMATION

    • ACCESS CODE 
    • NEW CLIENT INFORMATION 

    • NEW CLIENT INFORMATION

    • Child's date of birth*
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    • Please note that text reminders will go to

      the primary caregiver's cell phone number.

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    • Background Information 
    • Days Scheduled
    • What environments does your child regularly attend

    • Please describe your child's sleep/wake cycle:

    • General Information 
    • Have any other specialists (occupational therapist, physical therapist, audiologist, neurologist, neuropsychologist, ENT, orthopedist, behaviorist, etc) seen your child?*
    • Has your child been at risk for harm to self or others?*
    • Does your child or family have any spiritual or cultural variables that you would like us to be aware of in the intervention process?*
    • Are there any legal considerations that we should be aware of?*
    • BIRTH HISTORY 
    • Were there any difficulties during pregnancy, labor or delivery?*
    • Did the mother take any medication during the pregnancy?
    • Were there any complications at birth?*
    • Type of delivery
    • Method of delivery
    • Did your child suffer from any of these during the first 30 days of life?*

    • MEDICAL HISTORY 
    • Does your child wear glasses?*
    • Has your child's hearing been tested?*
    • Has your child experienced any ear infections?*
    • Were ear infections treated with

    • Does your child have any diet restrictions?*
    • Is your child currently taking any medications regularly?*
    • MOTOR DEVELOPMENT 
    • Rows
    • Does your child drool excessively for his/her age?*
    • Can your child ride a bike?
    • Rows
    • ACTIVITIES OF DAILY LIVING 
    • Rows
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    • Does your child get dressed in an appropriate time frame?*
    • Does your child seem overly sensitive to noises? (vacuum cleaner, garbage truck, movies, etc.)*
    • Does your child have favorite food?*
    • SPEECH AND LANGUAGE DEVELOPMENT 
    • Has your child had a previous speech and language evaluation?*
    • Has your child previously had speech and language therapy?*
    • Do any family members have hearing or speech/language difficulties?*
    • What is your child's most frequent means of communication (check all that apply)*
    • Does your child use words consistently to communicate?*
    • If so, please provide number of words used consistently
    • Rows
    • Does he/she have difficulty pronouncing any sounds?*
    • Is your child easily frustrated when he/she is not understood?*
    • Is your child aware of his/her communication difficulties?*
    • Other areas of general concern (please click all that apply)

  • We thank you for taking the time

    to fill out this form!

  • Date*
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