Prospective Speech-Language Therapy Client Form
Thank you for your interest in Aloha Behavioral Practice. We'd like to learn about how we can be of service to you. Please complete this intake questionnaire regarding your child and their needs.
General Information
The following section will ask you to provide general information, such as your name and relationship to the child.
Name of Individual Completing this Form
*
First Name
Last Name
Name of Child
*
First Name
Last Name
Relationship to the Child
*
Parent/Guardian
Uncle/Aunt
Grandparent
Child's Date of Birth
*
-
Month
-
Day
Year
Date
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Parent/Guardian Contact Information
Please provide your contact information below.
Parent/Guardian 1
*
First Name
Last Name
Parent/Guardian 2
First Name
Last Name
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian 1 Cell Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian 1 Email Address
*
example@example.com
Parent/Guardian 2 Cell Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian 2 Email Address
example@example.com
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Medical Information
The following section will inquire about the child's current physician and medical history.
Name of Child's Physician
*
First Name
Last Name
Physician's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Does your child have any current health conditions, including infectious diseases?
*
Yes
No
If yes, please describe below.
Does your child have any known medical conditions?
*
Yes
No
If yes, please list the conditions below.
If your child has received treatment for the conditions mentioned above, please provide the providers and durations of previous treatment.
If your child is currently receiving treatment for the conditions above, please provide the name(s) of the current treating clinician(s).
If your child is experiencing any therapeutic interventions, please mention below and include their response(s) to the interventions.
List any operations, serious illnesses, injuries (especially head), hospitalizations, allergies, ear infections, or other special conditions your child/adolescent has had below.
Does your child have any vision problems?
*
Yes
No
If yes, please explain below and if there are any treatments currently being used for correction.
Do you have any concerns regarding your child's ability to hear?
*
Yes
No
If yes, please explain below and provide any history of ear infections/hearing aids/ most recent audiological examination.
Does your child have a history of seizures?
*
Yes
No
If yes, please describe the types of seizures and current treatment.
Is your child currently taking any medications?
*
Yes
No
If yes, please name the medication(s) and the amount taken per dose.
If your child takes medication(s), please note how often they are taken below.
Does your child experience side effects as a result of taking their medication(s)?
*
Yes
No
If yes, please describe the side effects below.
Does your child have any allergies to medications?
*
Yes
No
If yes, please describe below, including any adverse reactions.
Does your child currently have a medical/ developmental diagnosis?
*
Yes
No
If yes, please provide the following information as prompted.
Please note that the diagnosis information is required for insurance coverage. By having this information, it assists us when speaking with your insurance company to get authorization for services and providing you with invoices for reimbursement through insurance.
If your child has a diagnosis, please name the diagnosis/diagnoses.
If your child has a diagnosis, please indicate the date they received the diagnosis/diagnoses.
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Insurance Information
This section will inquire about your insurance, including the name of your insurance company and Social Security Number.
Name of Insurance Company
*
Name of Policy Holder
*
First Name
Last Name
Social Security Number
*
Policy Holder's Date of Birth
*
-
Month
-
Day
Year
Date
Member ID
Group ID
Please provide us with a copy of the front and back of your insurance card if you are going to be seeking reimbursement for services through your insurance company.
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Current/Previous Therapy Provider Information
Please provide us with information regarding the following types of current or previous therapy providers and copies of any recent evaluations that indicate dates of previous treatment and therapeutic interventions and responses.
Has your child previously received speech therapy services?
*
Yes
No
If yes, please provide the provider's name, address, phone number and email.
Does your child currently receive any other therapy services?
*
Yes
No
If yes, please provide the provider's name, address, phone number and email.
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Educational History
Please provide your child's educational history below.
Is your child currently enrolled in school? If yes, what is the name of the school s/he is attending?
How many years has your child attended their current school so far?
What is your child's current grade at this school?
Does your child's current school offer Special Education Services?
Yes
No
Is your child currently eligible for Special Education Services?
*
Yes
No
Is your child currently receiving any school based services (ex. Speech, OT, PT, SAI services)?
Please provide us with copies of any reports from evaluations that you may have, as well as a copy of the current 504 plan or IEP.
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Family Background
Please provide information about your child/adolescent's family background as prompted.
Does either parent/guardian’s job require him/her to be away from home for long hours or extended periods of time that might prevent them from being involved in speech therapy appointments and parent training?
*
Yes
No
If yes, which parent/guardian and for how long?
If divorced, who has legal custody?
Does your child have siblings?
*
Yes
No
If yes, please list the name(s) and age(s) of their sibling(s) and indicate if they live at home.
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Psychological History
The following section will ask questions about the psychological history of the child/adolescent and their immediate and extended biological family.
Please indicate below whether there is a history of the following in your immediate family or in either biological parent’s extended family.
Autism Spectrum Disorders
Learning Problems/Disabilities
ADD/ADHD-Attention Problems
Clinical Depression
Bipolar Disorder
Behavior Problems in School
Anxiety Disorders (e.g., OCD, etc.)
Psychosis/Schizophrenia
Substance Abuse/Dependence
Speech/hearing impairment
If any of the above are checked, please indicate who in the family currently has or has had these diagnoses.
If you have other mental health concerns, describe them below.
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Birth and Development History
The following section will inquire about the birth and development of the child/adolescents.
Were there any complications with the pregnancy?
*
Yes
No
If yes, please describe the complications below and treatment details.
Was birth at full term?
*
Yes
No
If no, please provide details.
Were there any complications during delivery?
*
Yes
No
If yes, please describe the complications below and treatment details.
Were there any concerns at birth?
*
Yes
No
If yes, please describe the concerns and treatment details.
Where there any developmental milestones that your child/adolescent was delayed in or did not achieve?
*
Yes
No
If yes, please identitfy those milestones below.
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Current Behavioral Concerns
Please indicate if your child/adolescent engages in any of the following behaviors. Check all that apply.
Aggression
Hitting (e.g., punch, slap, etc.)
Kicking
Biting
Pinching
Head-butting
Scratching
Spitting
Other
Self-Injurious Behavior
Hitting self with hands or fists
Kicking self
Biting self
Head-butting walls, windows, etc.
Pulling teeth
Scratching skin
Cutting/burning
Other
If your child/adolescent hits, kicks, or bites themselves, please indicate where on the body this behavior is engaged.
Does your child elope (i.e., running out of a building, room, vehicle, etc.)?
*
Yes
No
Does your child experience sensory issues?
*
Yes
No
If yes, please describe below.
Additionally, please indicate if your child is experiencing any of the following. Check all that apply.
Difficulty with toileting
Problems with eating
Isolated socially from peers
Difficulty making friends
Problems keeping friends
Difficulty concentrating
Problems with sleeping
Bedwetting
Anxiety
Sadness or depression
Hallucinations
Delusions
Suicidal ideation/Attempts
Is there any additional information you would like for us to know?
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Current Speech and Language Concerns
What current speech/language concerns do you have for your child?
*
How often does s/he have difficulty being understood by familiar listeners (parents, siblings, close friends)?
*
Never
Rarely
Sometimes
Often
Always
How often does s/he have difficulty being understood by unfamiliar listeners (new friends, people at the store, other adults)?
*
Never
Rarely
Sometimes
Often
Always
Can you please provide specific examples of any misarticulations (ex: says /tat/ for /cat/)?
*
Does your child stutter? If yes, please describe frequency and any secondary characteristics associated with a disfluent moment (ex: facial tension, eye rolling, head movements, etc.)
*
If your child has siblings, do they have any history of speech/language impairment and/or treatment?
*
Parent Goals for Child
Please answer the questions below using options that best describes what you may have noticed with your child's speech-language abilities.
What are areas of strengths/interests for your child?
*
Do you have any worries or concerns about moving forward with assessment/treatment?
*
Yes
No
If yes, please describe.
What are your specific goals for speech-language therapy?
*
Do you have any concerns regarding your child's social skills?
*
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Daily Routines
Please answer the questions below so that we may get a better understanding of your child's daily routines.
Please describe what a typical day looks like for your child.
When your child needs your help, please detail how he/she gains your attention (hand leading, verbally asking for assistance, screaming, etc.).
What are your child's favorite things to do at home?
What is your ideal Speech Therapy schedule?
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Availability
Please provide us with several times your child would be available for an initial evaluation/ongoing sessions. We have times M-TH between the hours of 7am-5pm.
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