Alphabet Kids Patient Intake Form

Child's Name

First NameLast Name

Gender

Date of Birth

Date

Age

School

Grade Level

School/Daycare Schedule

Please List Preferred Days/Times for Therapy

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email for Appointment Reminders

Services you are interested in pursuing with Alphabet Kids

Language(s) Spoken at Home

Health Care Provider Name (Pediatrician) and Phone Number

ALLERGIES

MEDICATIONSALLERGIES

IF YES, PLEASE LIST

DATE OF DIAGNOSIS

DIAGNOSIS PROVIDED BY

Name of Physician/Provider

I have the legal right to give permission for therapy services, because my relationship to the child is:

Parent/Guardian Name - Primary

First NameLast Name

Parent/Guardian Preferred Pronouns

Phone Number - Primary

Please enter a valid phone number.Format: (000) 000-0000.

Email- Primary

example@example.com

Parent/Guardian Employer - Primary

Parent/Guardian Name - Secondary

Phone Number - Secondary

Please enter a valid phone number.Format: (000) 000-0000.

Emergency Contact (When neither guardian can be reached)

First NameLast Name

Emergency Contact Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Emergency Contact Relationship to Child

If Transferring or adding please tell us where from.

Does your child have an IEP?

Did your child use 1 word by the age of 1 year?

Did you child begin using 2 words by the age of 2 years old?

Does your child currently speak using 3+ word sentences?

Approximately how many words does your child currently have?

Does your child currently use sign or gestures to communicate?

If yes, what signs/gestures?

Does your child currently use a communication device to speak?

If yes, what device?

Does your child respond to his/her name?

Does your child try to get you to notice interesting objects?

When you point to a toy across the room, does your child look at it?

Does your child engage in pretend play with toys (i.e. feed a doll?)

Does your child play well with other children?

Do you have any concerns regarding socialization? If yes, please explain.

How does your child communicate in different settings? Home, community, school, etc.?

Did child pass newborn hearing screening?

Has your child had a history of ear infections or tubes placed.

Has your child had hearing testing done since the newborn screening? If so please list results. (Date of testing)

Is there a history of speech/language delays on either paternal or maternal side. (i.e. Speech or Language, Stuttering, Hearing loss, Cleft Palate, Autism Spectrum, Developmental Delay, Reading or Learning Disability, ADHD). If yes, please explain.

Parent/Guardian Signature