njpeakpediatrics.com-Child Intake Form

Child Intake Form
Child’s Name
Nickname
Date

MonthDayYear
Date
Gender:

MaleFemale
Age
Date of birth

MonthDayYear
Diagnosis (if known):
Parent(s) / Guardians:
Address

Street Address Line 2
Home Phone
Cell Phone
Email 1:
example@example.com
Email 2:
example@example.com
Emergency Contact Name and Number:
Emergency Contact Relationship to Child:
Child’s Physician:
Physician Phone Number:
Physician Address:
How did you hear about Peak Pediatrics LLC?
Family Background
Parent 1 Name:
Occupation:
Parent 2 Name:
Occupation:

Does the child have siblings?

	Age	Sex	Speech Issues
Child 1 Name:
Child 2 Name:
Child 3 Name:
Child 4 Name:

Language(s) spoken in the home:
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 are seeking an evaluation at this time:
Has the child had a previous speech/language evaluation / treatment?

YesNo
By whom:
When
Describe the results:
At what age did you first notice the problem?
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:
Check and describe all that apply:

AsthmaBehavior IssuesBrain injury
Describe
Describe
Describe
Breathing problemsHeart issuesDiabetes
Describe
Describe
Describe
Ear infectionsSeizuresSleep issues
Describe
Describe
Describe
Tongue tieTraumatic brain injuryVision issues
Describe
Describe
Describe
Is the child up to date with immunizations:

YesNo
Please describe:
Has the child ever had surgery?

YesNo
Please describe:
Has the child ever been hospitalized:

YesNo
Please describe:
Has the child ever been in a serious accident?

YesNo
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?

YesNo
Please 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?

YesNo
Please describe:
Does the child have any known hearing loss?

YesNo
Please describe:
Is the child currently receiving any of the following services? If yes, please check and describe.

Physical TherapyOccupational TherapySpeech-Language
Describe
Describe
Describe
Behavioral TherapyPsychological Therapy/Counseling
Describe
Describe
Developmental History

At what age did the child do the following:
Walk: . First Word: blank .
Combined Words . Sentences: blank.
Does the child do any of the following:

Choke on liquidsChoke on foodsAvoid foodsMaintain a special dietUse a pacifier / suck thumbMouth objects
Please describe any of the above
If under 4 years of age, how many words does the child say:

0-2021-5051-100101-150151-300301-500501+
Does your child say:

1 word2 words3 words4 words5+ words
What percentage of the child’s speech do you understand? blanks %.
How well do people outside of the family understand their speech? blanks %.
If the child is not using words, how do they communicate?
Does the child have any difficulty with the following:

AttentionFrustrationAggressionAngerAnswering simple questionsAnswering –wh questionsUnderstanding peopleFollowing directionsExcessive droolingChewing or eatingProducing speech soundsStutteringReadingSchool-workRememberingEye contactTransitionsWord RetrievalOther
Has the child experienced any difficulty with feedingor swallowing? If so, please describe:
Educational History
Is the child currently enrolled in daycare/ school:

YesNo
What is the name of the program?
What is their grade level:
Please describe any educational difficulties or learning challenges that this child has faced:
Social History
What are the child’s strengths?
What are the child’s weaknesses?
Describe any significant events or changes within the home:
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 thechild interacts with other children:
What are your goals for the child over the next 6 months?
Is there anything else that is important for us to know about the child?
Person filling out the form:
Should be Empty: