First Name of Child
Last Name
Age
Birth Date
First Name - Person Completing Form
Last Name
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Relationship
Name of family members living at home:
Language(s) spoken in the home:
Were there any problems during pregnancy or difficulties at birth?
Yes
No
Was your child born before the due date?
Yes
No
Has your child been hospitalized at any time?
Yes
No
Has your child had his or her vision checked?
Yes
No
Are there any diagnosed mental, physical, or emotional disabilities?
Yes
No
Does your child have any allergies?
Yes
No
If you checked "YES" to any of the above, please explain or describe here:
Does your child talk in a very loud voice?
Yes
No
How does your child usually let you know what he or she wants? Check all that apply:
Cries
Points to what he or she wants
Uses a few words
Makes a few different sounds
Makes many different sounds
Uses gestures (e.g., gestures for "give it to me")
Says many words, but no phrases or sentences
Says two or three-word sentences
Uses long sentences
Other
Does your child turn up the volume on the radio and TV?
Yes
No
Does your child hear you if his or her back is turned
Yes
No
Does your child hear you if you talk to him or her from the other room?
Yes
No
Does your child have a history of year infections?
Yes
No
How many? When was the most recent?
Has your child had a hearing test?
Yes
No
Additional Comments or Examples:
Additional comments/examples:
Does your child answer when you talk to him or her?
Yes
No
Does your child talk about what he or she is doing?
Yes
No
Does your child ask for help?
Yes
No
Can the family understand your child's speech?
Yes
No
Can people outside of the family understand your child's speech?
Yes
No
What does your child talk about?
My child ______ been enrolled in therapy/treatment before.
has
has not
Comments about previous therapy:
I think my child has trouble with:
I would like my child to learn how to: (Rank by most important to least important)
My family ______ available to participate in the treatment program.
is
is not
Additional Concerns
Submit
Should be Empty: