Patient Intake Form

Alphabet Kids Patient Intake Form
Child's Name

First NameLast Name
Gender
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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 (Found on Insurance Card)
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
Does your child have an IEP?
Approximately how many words does your child currently have?
Does your child currently use sign or gestures to communicate?
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
Should be Empty:

Alphabet Kids Patient Intake Form