Alphabet Kids Patient Intake Form
Child's Name
*
First Name
Last Name
Gender
*
Male
Female
Other
Date of Birth
*
-
Month
-
Day
Year
Date
Age
*
School
*
Grade Level
*
School/Daycare Schedule
*
Please List Preferred Days/Times for Therapy
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email for Appointment Reminders
*
Services you are interested in pursuing with Alphabet Kids
*
Speech Therapy
Feeding Therapy
Occupational Therapy
ABA Therapy
Language(s) Spoken at Home
*
Health Care Provider Name (Pediatrician) and Phone Number
*
ALLERGIES
*
Yes
No
MEDICATIONSALLERGIES
*
Yes
No
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:
*
Custodial parent
Legal guardian
DHS caseworker
Parent/Guardian Name - Primary
*
First Name
Last 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 Name
Last 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?
*
Yes
No
In Process
Did your child use 1 word by the age of 1 year?
*
Yes
No
Did you child begin using 2 words by the age of 2 years old?
*
Yes
No
Does your child currently speak using 3+ word sentences?
*
Yes
No
Approximately how many words does your child currently have?
*
Does your child currently use sign or gestures to communicate?
*
Yes
No
If yes, what signs/gestures?
*
Does your child currently use a communication device to speak?
*
Yes
No
If yes, what device?
*
Does your child respond to his/her name?
*
Yes
No
Does your child try to get you to notice interesting objects?
*
Yes
No
When you point to a toy across the room, does your child look at it?
*
Yes
No
Does your child engage in pretend play with toys (i.e. feed a doll?)
*
Yes
No
Does your child play well with other children?
*
Yes
No
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?
*
Yes
No
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
*
Submit
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