• NEW CLIENT INFORMATION

  • ACCESS CODE

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    • CLIENT INFORMATION

    • Child's date of birth*
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      2 digit month, 2 digit day, 4 digit year
    • Services you are interested in:*

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    • BACKGROUND INFORMATION

    • Days Scheduled
    • Movement and Balance/Posture:
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    • Gross Motor Skills:
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    • Sensory:
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    • Fine Motor Skills:
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    • Writing:
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    • Behavioral/Social:
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    • Organization:
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    • Activities of Daily Living:
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    • Does your child tolerate:*
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  • Articulation:
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  • Expressive Language:
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  • Receptive Language:
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  • Fluency:
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  • Voice:
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  • Academic Skills:
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    • BIRTH / DEVELOPMENTAL HISTORY

    • Were there any difficulties during pregnancy, labor or delivery?*
    • Were there any complications at birth?*
    • Type of delivery
    • Method of delivery
    • Is your child adopted or in the foster system?*
    • Did your child have any of these concerns during the first 30 days of life?*

    • Developmental Information (Please check if these milestones occurred on time)
    • Can your child ride a bike?*
    • Please mark your child's love or avoidance of playground equipment:*
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  • MEDICAL HISTORY

  • Is your child currently taking any medications regularly?*
  • Do you have any concerns about your child's diet?*
  • Does your child wear glasses or contacts?*
  • Has your child's hearing been tested?*
  • Has your child experienced any ear infections?*
  • Were ear infections treated with

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

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    • GENERAL INFORMATION

    • Have any other specialists (occupational therapist, physical therapist, audiologist, neurologist, neuropsychologist, ENT, orthopedist, etc) seen your child?*
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    • Date*
       - -
      2 digit month, 2 digit day, 4 digit year
  • Please indicate the age (in months) that your child reached each milestone:*
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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?*
  • Please indicate your child's ability to perform the following self help skills:
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  • 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
  • Does your child:*
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  • 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?*
  • Does your child drool excessively for his/her age?*
  • Other areas of general concern (please click all that apply)

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