2023 Child Intake Questionnaire

SPEECH-LANGUAGE THERAPY SERVICES
9620 Chesapeake Dr. Suite 103 San Diego, CA 92123
p: (858) 952-8077 f: (858) 541-2600

Today's Date

Date

Client Name

Nickname

Date of Birth

Date

Age

Gender

Diagnosis (if known)

Parent(s) / Guardians

Address

Street Address Line 2

City, State, Zip

Phone #

Format: (000) 000-0000.

Email

example@example.com

Client's Physician

Physician Phone Number

Format: (000) 000-0000.

Physician Address

Other Physicians / Specialists Involved In Care:

Referring Physician

Phone Number

Format: (000) 000-0000.

Physician Address

Secondary Physician

Phone Number

Format: (000) 000-0000.

Physician Address

How did you hear about Optimize Speech Language Therapy Services?

Parent 1 Name

Age

Occupation

Education Level

Parent 2 Name

Age

Occupation

Education Level

Marital Status

What adults does the child live with? Check all that apply

Does the child have siblings or are there other siblings in the home? Please list siblings & ages.

Language(s) are spoken in the home

Who speaks the other language(s)?

Describe the child's use/understanding of the language(s)

Tell us about the family / home environment?

Briefly describe why you're seeking an evaluation by a speech language pathologist at this time

What are you expecting out of this evaluation / meeting?

Has the child had a previous speech, language or feeding evaluation/treatment?

By whom

When

Describe the results

Describe in your own words the nature of your concerns about the child's development and/or the primary referral reasons

At what age did you first notice the problem?

How do the child's communication difficulties impact the family?

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?

Describe any pertinent information about the child's medical history (surgeries, diagnoses, etc.) as well as when they were diagnosed and by whom

Mother's Health During Pregnancy:

1. Were there any infections or illnesses?

Describe

2. Was there any stress during the pregnancy?

Describe

3. Were there any complications during labor or delivery?

Describe

4. What was the mother's age at the time of delivery?

Child's Health:

1. How many weeks gestation was the child born? weeks (40 weeks is typical) Weeks

2.The child was blanks lbs and oz

3. How was the child delivered?

4. Please describe any complications or concerns during labor or delivery

Check and describe all that apply:

Is the child up to date with immunizations

If no, please describe

Has the child ever had surgery?

Please describe

Has the child ever been hospitalized

Please describe

Has the child ever been in a serious accident?

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 1

Medication 2

Medication 3

Medication 4

Please list any allergies your child has:

Does the child currently use any equipment? (communication device, walker, etc.) If yes, please describe:

Does the child have a history of ear infections, tubes, etc. or use hearing aides?

If yes, please describe:

Does the child have any known hearing loss?

If yes, please describe:

If you have any concerns about the child's hearing, please describe

Describe the child's current health status

Is the child currently receiving any of the following services? If yes, please list the person’s name and last date of service.

At what age did the child do the following:

Sit alone

Crawl

Stood Up

Walk

Sounds

First Word

Combined Words

Sentences

Toilet Trained

Does the child do any of the following

Please describe any of the above

Has the child experienced any difficulty with feeding or swallowing? If so, please describe

Are mealtimes stressful to you or your child? Please describe.

Does your child use a pacifier? If yes, please share when and for how long.

If under 4 years of age, how many words does the child say:

Does the child produce sentences of the following length:

What percentage of the child's speech do you understand?

How well do people outside of the family understand their speech?

If the child is not using words, how do they communicate?

Does the child have any difficulty with the following

Please describe any of the above

Educational History

Is the child currently enrolled in daycare/school

What's the name of the program?

What days do they attend?

Grade

Type of classroom

Do they have a current IEP?

Please list any accommodations that your child receives (e.g., alternative seating, noise cancelling headphones, AAC,IEP supports, sensory supports)

Please describe any educational difficulties or learning challenges that this child has faced

Social History

Describe how the child interacts with parents, siblings, or other family members

Please describe the communication difficulties the child faces in the home environment

Describe any significant events or changes within the home (ex: moving, new sibling, parent deployed,new school, etc)

What comes easily to your child?

What does your child need more support with? What daily challenges do they face?

What are the child's favorite activities?

Does the child participate in any community activities (ex. play groups, sports, etc.) If yes, please describe.

Does the child become easily frustrated with certain activities? If so, please explain

Describe how the child interacts with other children

What are your goals for the child over the next 6 months?

What are your goals for the child over the next 5 years?

Is there anything else that is important for us to know about the child?

Person filling out the form

Relationship to the child

Please verify that you are human

Child Intake Form/History

Family Background

Evaluation

Medical History

Developmental History