2023 Child Intake Questionnaire

Child Intake Form/History
SPEECH-LANGUAGE THERAPY SERVICES
9620 Chesapeake Dr. Suite 103 San Diego, CA 92123
p: (858) 952-8077 f: (858) 541-2600
Today's Date

MonthDayYear
Date
Client Name
Nickname
Date of Birth

MonthDayYear
Date
Age
MaleFemale
Diagnosis (if known)
Parent(s) / Guardians
Address

Address

Street Address Line 2

City, State, ZipState / Province

Postal / Zip Code
Phone #
Format: (000) 000-0000.
CellHomeWorkOther
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?
Family Background
Parent 1 Name
Age
Occupation
Education Level
Parent 2 Name
Age
Occupation
Education Level
SingleMarriedDivorcedSeparatedWidowed
Birth Parent(s)Adoptive Parent(s)Foster Parent(s)Grandparent(s)Both ParentsParent 1 OnlyParent 2 OnlyOther
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?
Evaluation
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?
YesNo
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?
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
Mother's Health During Pregnancy:
YesNo
Describe
YesNo
Describe
YesNo
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 blank oz and blank inches at birth
VaginallyCesarean Section
4. Please describe any complications or concerns during labor or delivery
Adenoidectomy
Behavior Issues
Brain Injury
Breathing Problems
Cardiac Issues
Chicken Pox
Diabetes
Ear Infections
Ear Tubes
Encephalitis
Frequent Colds
High Fever
Seizures
Sensory Issues
Sleep Issues/Snoring
Tongue Tie
Tonsilitis
Tonsillectomy
Traumatic Brain Injury
Vision Issues
YesNo
If no, please describe
YesNo
Please describe
YesNo
Please describe
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 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:
YesNo
If yes, please describe:
YesNo
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.
Developmental Pediatrician
Neurologist
PT
OT
SLP
Behavioral Therapist
Educational Consultant
Psychologist/ Psychologist
Vision Therapist
Other
Developmental History
At what age did the child do the following:
Sit alone
Crawl
Stood Up
Walk
Sounds
First Word
Combined Words
Sentences
Toilet Trained
Choke on liquidsChoke on foodsAvoid foodsMaintain a special dietUse a pacifier / suck thumbMouth objects
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.
0-2021-5051-100101-150151-300301-500501+
2 words3 words4 words5+ words
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?
AttentionFrustration ToleranceAggressionAngerAnswering simple questionsAnswering -wh questionsAwareness of SurroundingsFollowing directionsDroolingChewing or eatingProducing speech soundsStutteringReadingSchool workMemoryParticipation in partner/group activitiesTransitionsWord RetrievalPlay with piers/peer interactionsOther
Please describe any of the above
Educational History
YesNo
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*
Should be Empty:

Child Intake Form/History

Family Background

Evaluation

Medical History

Developmental History