Children's Intake Form
Patient's Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Sex
*
Male
Female
Parent's Name
*
First Name
Last Name
Parents are...
Married
Divorced
Separated
Single
Widow
Address
Email Address
*
example@example.com
Phone/Mobile Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Person and Contact Number
*
Siblings (name and age)
Other significant people (i.e. others who live with your child, share a main caring role or frequently spend time with your child. For example, grandparents, nannies)
*
Child's Pediatrician (Name, Contact Number & Address)
How did you hear about us?
STATEMENT OF PROBLEM
When was this problem first noticed?
*
What strategies at home seem to help?
*
How has the problem changed/evolved?
*
What professional services has your child received and when?
*
DEVELOPMENTAL HISTORY
What age did your child achieve the following milestones:
Crawled:
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Walked:
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Grasped crayon/pencil:
*
Sat alone:
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Toilet trained:
*
Drank from a cup:
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Self-fed:
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Does you child:
Choke on foods or liquids?
*
Yes
No
Brush his/her teeth and/or allow brushing?
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Yes
No
Currently put toys/objects in his/ her mouth?
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Yes
No
MEDICAL HISTORY
Was there anything unusual about the pregnancy or birth?
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Yes
No
If yes, please describe:
Was this child adopted?
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Yes
No
If yes, at what age? Is native language spoken?
Was the child full term?
*
Yes
No
If premature, by how many weeks?
Briefly describe delivery:
Child's weight at birth:
Were any special treatments or medications given to the child at birth or in the following days/weeks?
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Yes
No
Please describe:
Did your child have any feeding/ swallowing problems as an infant/ toddler?
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Yes
No
Please describe:
Did your child use a pacifier? If yes, until what age?
*
Did he/she suck their thumb/fingers? If yes, until what age?
*
Has your child experienced any of the following:
*
Adenoidectomy
Sleeping difficulties
Tonsillectomy
Ear tubes
Sinusitis
Frequent colds
Ear infections
Seizures
Allergies
Vision problems
Other
Please list any medications your child takes regularly:
*
SPEECH, LANGUAGE AND HEARING HISTORY
As an infant, did your child babble and play with sounds?
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Yes
No
When did your child speak his/her first word?
*
When did he/she begin to use 2-word phrases?
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Does he/she use speech:
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Always
Occasionally
Never
Does he/she prefer to use gestures? If so, give examples:
Which option(s) best describes the manner in which your child currently communicates:
5+ word sentences
2-4 word phrases
Single words
Sounds
Gesture
Examples of child’s speech:
How well can your child be understood by parents: (Use %)
How well can your child be understood by siblings: (Use %)
How well can your child be understood by friends: (Use %)
Does your child understand and follow simple directions?
Yes
No
How well can your child be understood by strangers: (Use %)
Has speech/language been tested? By whom and when?
Has your child received speech therapy in the past? If yes, where/when? What were they working on?
Has your child received any other evaluation or therapy? (e.g. physical therapy, counseling, occupational therapy, vision etc)?
Yes
No
Is your child aware of, or frustrated by, their speech/language difficulties?
Yes
No
Maybe
Has vision been tested? By whom and when?
Has hearing been tested? By whom and when?
What do you see as your child’s most difficult challenge at home:
What do you see as your child’s most difficult challenge at school:
Which language/s does the child speak?
Which language/s does the child understand?
What language(s) is/are spoken at home?
Does your child....
Repeat sounds, words or phrases over and over?
Yes
No
Understand what you are saying?
Yes
No
Retrieve common objects upon request (ball, cup, shoe etc)?
Yes
No
Follow simple directions, (i.e. “Please shut the door”)
Yes
No
Respond correctly to who/ what/ where/ when/ why questions?
Yes
No
Follow simple directions outside of typical routines?
Yes
No
What games/ toys/ activities does your child prefer?
Does your child make any sounds incorrectly? If yes, which ones?
Is there a family history of speech, language, learning, or feeding difficulties?
Yes
No
EDUCATIONAL INFORMATION
School and Grade
Teacher's Name
Does your child receive support services (IFSP/IEP) at school?
How does your child feel about school/ teachers?
Is your child having difficulty with any particular subjects? If yes, please describe:
What are your child’s strengths and/or best subjects?
BEHAVIORAL CHARACTERISTICS
Please check all traits which best characterizes your child’s current behavioral characteristics:
Cooperative
Easily distracted
Destructive/ aggressive
Poor eye contact
Withdrawn
Overly sensitive to lights
Overly sensitive to sounds
Separation difficulties
Attentive
Easily frustrated/impulsive
Humorous
Inappropriate behavior
Perfectionist
Mature for age
Greets people
What would be your primary goals for us to keep in mind?
Do you have any additional information you would like us to know?
I give permission for the speech therapists from Chatham Speech and Language to speak to my child’s teacher, tutor, doctor, or other therapists for the purpose of sharing the results of evaluations, discussing progress, and supporting my child in any way.
*
I allow
Signature
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