Intake: Pediatric
Speech and Language
Identifying Information
Client Name
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First Name
Middle Name
Last Name
Name of person completing form
*
First Name
Last Name
Today's Date
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 -
Month
 -
Day
Year
Date
Client's Date of Birth
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 -
Month
 -
Day
Year
Date
Child's Age
*
Gender
*
Please Select
Male
Female
Other
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Has the child had a previous speech, language, or feeding evaluation?
*
Please Select
Yes
No
When
Describe the concerns for previous evaluation(s):
Concern/complaint for today's visit:
*
When were concerns first noticed?
*
Primary care physician/Pediatrician
First Name
Last Name
How did you hear about Shore Therapy Services?
*
Please Select
Google
Word of Mouth
Insurance company
Physician
Other
Please specify the name of the referral source: e.g. name of physician or "word of mouth" source:
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Family Background
1- Caregiver/Guardian
*
First Name
Last Name
Primary Number
*
Please enter a valid phone number.
Secondary Number
Please enter a valid phone number.
Email
*
example@example.com
Martial Status
*
Please Select
Married
Single
Divorced
Separated
Widowed
Occupation
*
Are there other parent(s)/legal guardians
Please Select
Yes
No
2-Caregiver/Guardian
First Name
Last Name
Primary Number
Please enter a valid phone number.
Secondary Number
Please enter a valid phone number.
Email
example@example.com
Martial Status
*
Please Select
Married
Single
Divorced
Separated
Widowed
Occupation
*
Are there any custody issues in the family?
Please Select
Yes
No
If 'yes', please explain.
What other adults does the child live with? Check all that apply.
*
Birth Parent(s)
Adoptive Parent(s)
Foster Parent(s)
Parent 1 only
Grandparent(s)
Other
Does the child have siblings or are there other children in the home?
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Yes
No
Please list the names, ages, and any development and/or speech disorders of siblings:
Is the child exposed to more than one language?
Please Select
Yes
No
Primary language exposed to:
Other Language(s) exposed to:
Is there anything additional you would like to share about your family?
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School/Education
Does the child attend school/daycare
*
Please Select
Yes
No
Name of school
Child's current grade:
What day's do they attend?
Length of day:
Please Select
Part-time
Full-time
Describe any education difficulties:
Has the child had a child study team evaluation?
Please Select
Yes
No
When was their last child study team (CST) evaluation:
 -
Month
 -
Day
Year
Date
Current therapies received in school:
None
Speech Therapy
Physical Therapy
Occupational Therapy
Psychology
Other
Please describe any of the following: Classification (e.g IEP, 504, OHI (other health indicator. (e.g. IEP, 504, OHI (Other Health Indicator), accommodations, etc):
Are there any other childcare, babysitter's, or family members who regulary care for the child?
*
Please Select
Yes
No
Explain.
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Birth History
Mother's healthy during pregnancy
Were there any infections or illnesses
*
Please Select
Yes
No
Explain
Was there any stress during the pregnancy?
*
Please Select
Yes
No
Explain
Were there any complications during labor and delivery
*
Please Select
Yes
No
Explain
What was the mother's age during the time of delivery?
Child's healthy during pregnancy
How many weeks gestation was the child born?
*
The child was
blanks
pounds/ounces and
blank
inches at birth.
How was the child delivered?
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Please Select
Vaginal
Planned cesarean section
Emergency cesarean section
Were there any complications during labor or delivery?
*
Please Select
Yes
No
Described any complications or concerns during labor or deliver.
Medical History
Check all that apply:
Adenoidectomy
Asthma/reactive airway disease
Behavioral Issues
Brain Injury
Breathing Problems
Cardiac Problems
Chicken Pox
Diabetes
Ear Infections
Ear Tubes
Encephalitis
Frequent Colds/cough
High Fevers
Measles
Meningitis
Mumps
Seizures
Sensory Issues
Sleep Issues
Tongue Ties
Tonsillitis
Tonsillectomy
Traumatic Brain Injury
Gastrointestinal Issues
Muscular Skeletal Issues
Growth concerns
Skin issues
Eating/Swallowing concerns
Other
None of the below
Please describe above:
Are the child's immunizations up-to-date?
*
Please Select
Yes
No
Has the child had any surgeries?
*
Please Select
Yes
No
Please describe:
Has the child ever been hospitalized?
*
Please Select
Yes
No
Please describe:
Has the child ever been in a serious accident?
*
Please Select
Yes
No
Please describe:
Does the child have a chronic illness?
*
Please Select
Yes
No
Please describe:
Is the child currently on and medications?
*
Please Select
Yes
No
List medications:
Does the child have any allergies?
*
Please Select
Yes
No
List allergies:
Does the child use any specialized equipment?
*
Please Select
Yes
No
Please explain:
Describe the child's current health status:
*
Is the child receiving any of the following services?
None of the below
Developmental Pediatrician
Neurologist
PT
OT
SLP
Behavioral Therapist
Educational Consultant
Psychologist/mental health services
Vision Therapist
Allergist
Gastroenterologist
Dentist
Pulminologist
ENT
Other
Please describe and/or list any other specialists involved in child's care:
Has your child had their hearing tested?
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Yes
No
If so, when
Hearing impairment?
*
Please Select
Yes
No
Describe
Vision impairment?
*
Please Select
Yes
No
Describe
Developmental History
Do you have concerns for atypical or unusual behaviors?
Please Select
Yes
No
Please describe
Has the child had regression (loss of skills) in development?
Please Select
Yes
No
Please describe.
Does the child have difficulty with any of the following?
None of the below
Attention
Frustation tolerance
Answering -wh questions
Following directions
Agression
Answering simple questions
Understanding people
Producing speech sounds
Reading
Remembering
Word retrieval
School work
Transitioning
Maintaining eye contact
Stuttering
Chewing/eating
Other
Please describe
GROSS MOTOR
Are there any concerns for gross motor development?
*
Please Select
Yes
No
Please describe any additional concerns:
Age first sat alone:
Age began crawl:
Age first walked independently:
Select all your child is currently doing:
Jumping
crawling up/down stairs
Walking up/down stairs
Kicks a ball
Runs without falling
Squats and stands back up without support
FINE MOTOR
Are there any concerns for fine motor development?
*
Please Select
Yes
No
Please describe:
Select all your child is currently doing:
Throws a ball with direction
Catches a large ball
Turns pages in a picture book
Isolates index finger to point/poke
Removes/dumps out objects from a container
Can place a simple shape into a puzzle board
Scribbles with a crayon
Imitates lines made with a crayon/pencil
Builds block towers of 2 or more blocks
Builds block tower of 4 to 6 blocks
Is able to screw/twist the lid of a container
Picks up small objects with fingers
FEEDING/SWALLOWING
Are there any concerns for feeding development?
*
Please Select
Yes
No
Please describe any additional concerns:
Please select all that apply:
Choke on liquids/solids
Avoids foods
Special diet
Mouths objects beyond age expectancy
Gags on foods
None apply to my child
Does your child use a pacifier and/or suck thumb/fingers?
Yes
No
Was/is your child breast or bottle fed
Please Select
Breast
Bottle
Combination
If weaned from breast/bottle, when did they transitioned from breast/bottle
Current method of liquid intake (select all that apply)
Feeding tube
Syringe
Breast
Bottle
Spout cup/sippy cup
Straw
Open cup
Infa-trainer
spoon
fork
Current Nutrition intake (select all that apply)
Breast milk
Formula
Cow's milk
Smoothies
Puree
Mixed textures
Soft solids
Hard solids
Other
Nutritional supplements?
Yes
No
Does your child eat solid foods
Please Select
Yes
No
Feeding method
Adult feeds
Uses hands to self feed
Self feeds with utensils
Length of feedings/meals:
Less than 30 minutes
Greater than 30 minutes
How do you know your child is hungry/thirsty
Through schedule/anticipation
Interpreting cries/vocalizations
Child uses gestures
Child uses words
Other
Please describe/provide examples of how your child expresses hunger/thirst (i.e. examples of words/sentences/gestures they use:
Family goals for feeding:
Gain weight
Reduce mealtime stress
Wean from feeding tube
Improve function
Learn to self feed
Go to a restaurant/fathering
Accept new foods
Other
SOCIAL DEVELOPMENT:
Are there any concerns for social skills?
*
Please Select
Yes
No
Please describe:
Describe the child's favorite activities
Does the child participate in any community activities (e.g. play groups, clubs, etc)
Please Select
Yes
No
Please list
Describe how the child interacts with other children
SPEECH AND LANGUAGE DEVELOPMENT
Do you have concerns for your child's speech/language development:
Yes
No
If yes, please describe specific concerns:
How do the child's communication difficulties impact the family?
Is the child aware of or frustrated with communication difficulties?
Please Select
Yes
No
Please describe
Do any other family members have a speech/language, learning, or developmental diagnoses?
Please Select
Yes
No
Please describe
Does your child understand the following (check all that apply)?
Responds to name
Shows named people
Shows named objects
Shows named actions
Shows named body parts
Does your child understand the following (check all that apply)?
Points to named pictures
Follows directions with gestures
Follows directions without gestures
Follows multi-step commands
Colors
Shapes
Letters
Numbers
Does the child babble or vocalize consonants/vowel sounds
Please Select
Yes
No
My child is beyond this stage
Does your child use any spoken words?
*
Please Select
Yes
No
Describe how your child communicates with you.
How many words do they use:
1-5
6-20
21-50
51-100
101-150
151-300
301-500
501+
Please list the child's words, if vocabulary is less than 50 words
Check other manners of communication your child uses:
Needs are anticipated
Vocalizations (without words)
Reaching/pointing
Head nods
Waving
Clapping
Complex gestures
Uses words
Uses phrases/sentences
Describe:
Is your child using phrases or sentences?
Please Select
Yes
No
If yes:
2 words
3 words
4 words
5+ words
Give some examples of phrases/sentences your child uses:
Does your child use gestures or words for the following communication purposes
Request
Label
Comment
Call a person
Reject objects/actions
Yes/no
Greeting others
Answer questions
Ask questions
To tell/re-tell a story or event
Does your child usually attempt to imitate words when asked
*
Yes
No
Does your child attempt to imitate phrases/sentences
*
Yes
No
What percentage of the child's speech do familiar listeners understand?
What percentage of the child's speech do unfamiliar listeners understand?
Do you have concerns for your child's clarity of speech (how they pronounce sounds/words?
Yes
No
Unsure
If your child has trouble with speech clarity, give examples of errors they produce (e.g. "cat' is said as 'ca', 'happy' as 'ha-ee', "key' as 'tea', etc):
*
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Describe your goals for the child over the next 6 months
Additional comments/information
Signature
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