Language Lounge Intake Form

Welcome to The Language Lounge!

Thank you for choosing The Language Lounge to help meet your child’s communication and/or feeding needs. We realize there are many options from which to choose and we appreciate the opportunity to assist you with this important process.
Please take time to fill out as much information as possible regarding your child’s developmental history as this information can be vital to the direction of the therapy plan. We understand that these forms can be time consuming; however it is important that we have as much information as possible prior to your first visit so that we may provide the best possible service for your child. If your child has any recent evaluations completed by other health professionals (psychologist, IEP, etc.). Please complete and submit. We look forward to meeting you and your child!
Sincerely,
Frangelica Leo, M.S., CCC-SLP, TSSLD
Clinical Director of Related Services
Speech-Language Pathologist

Child's Name

First NameLast Name

Date of Birth

MonthDayYear

Primary phone Number

Area CodePhone Number

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Parent/Guardian Name

First NameLast Name

Cell no

Area CodePhone Number

E-mail

Primary Language spoken in the home

Previous evaluation list

Therapy to date

Describe present concerns

Does your child have a diagnosis?

YesNoin process of conculding

If yes, what is diagnosis and when was it diagnosed?

Had there been any significant changes in the last 6 months? Explain

Todays Date

MonthDayYear

Pre-natal/Birth History

Full term

YesNo

If no, how many weeks?

Birth Hospital

Illnesses or accidents during pregnancy

Use of alcohol, tobacco or medications during pregnancy:

Birth weight

Delivery:

Other unusual conditions that may have affected pregnancy or birth

Medical History

Please check if your child has had any of the following (and if so, at what age):

Check all that apply

Explain any checked items here

Are immunizations current?

Current General Health

Has your child had any earaches/ear infections?

If yes, please explain here

Allergies? (Describe)

Any other serious or recurrent illnesses?

Any operations? Explain

Any accidents? Explain

Any medications? (Past)

Current Medications

Vision problems? Treatment

Hearing difficulties? Treatment

Dental problems? Treatment:

DEVELOPMENTAL HISTORY

Age when child: (If you cannot remember specific time, please indicate if it occurred at the expected time or if it was delayed)

sat up alone

crawled

walked

toilet trained

dressed self

tied shoes

fed self independently

Weaned from bottle/breast

Is the child left or right handed?

Able to use:

open cupspoonstraw

Any difficulty ? Check those that apply

SwallowingChewingDrinkingDrooling

Food allergies

Favorite Foods

Aversive Foods (if any)

Attention span-for self-directed activities

Adult-directed

Eating and sleeping patterns

Does your child respond typically to light?

Does your child respond typically to people?

Does your child respond typically to sound?

Does your child:

Play with others? Who?

Eat and sleep well

Laugh?

Cry appropriately?

Smile?

Make wants/needs known?

How does he/she make needs known?

Does your child show unusual behavior (explain)?

LANGUAGE DEVELOPMENT

Age when your child:

spoke first word

combined words?

spoke in sentences?

first sentence?

Which sounds (if any) are incorrect?

How many words can your child say? (list if fewer than fifteen)

How long are your child's sentences?

Does your child have any difficulty understanding you? (describe)

Does your child have difficulty following directions? (describe)

Any speech or hearing problems in the immediate or extended family (explain)?

SOCIAL DEVELOPMENT

Names and ages of siblings:

Other adults living in the home

Moves prior to age 10

Relationship with peers

Number of regular playmates

Ages:

Gender

Activities shared with parents and siblings

How does your child handle...

frustration?

conflict?

separation?

Regular responsibilities

Favorite people, toys, snacks, activities, tv shows

What motivates your child most?

What discipline methods work best?

SCHOOL HISTORY

Child’s Current School and Grade

Child’s performance educationally

Receiving special services at school? if so which ones? How often?

How does your child's teacher describe his/her performance?

Has the teacher expressed any concern? If so, what?

Anything else you would like us to know about your child?

CONTACT INFORMATION

At times we may need to contact you for appointment reminders or other concerns. Please complete only the items below that you authorize as a method of contact. Note: Home address, one phone number and one e-mail address are required.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Preferred E-mail

Peferred phone number

Area CodePhone Number

Health Policy

Help and cooperation is required in order to maintain a healthy environment. A child must be
Temperature-free for 24 hours before returning to therapy. If your child has vomiting and/or
diarrhea, he/she should not return to therapy until 24 hours have passed since the last episode of the same. Children will not be seen if any of the following is present:
 Too ill or uncomfortable to function in the therapy setting
 Continual runny nose
 Thick or discolored nasal discharge
 Excessive sneezing or coughing and mucus-producing cough
 An elevated temperature.
Please contact your therapist and cancel session if the above applies to your child.

Duty to Warn and Protect

When a client discloses intentions or a plan to harm another person or persons, the health care professional is required to warn the intended victim and report this information to legal authorities. In cases in which the client discloses or implies a plan for suicide, the health care professional is required to notify legal authorities and make reasonable attempts to notify the family of the client.

Public Safety

Health records may be released for the public interest and safety for public health activities, judicial and administrative proceedings, law enforcement purposes, serious threats to public safety, essential government functions, military, and when complying with worker’s compensation laws.

Abuse

If a client states or suggests that he or she is abusing a child or vulnerable adult, or has recently abused a child or vulnerable adult, or a child (or vulnerable adult) is in danger of abuse, the health care professional is required to report this information to the appropriate social service and/or legal authorities. If a client is the victim of abuse, neglect, violence, or a crime victim, and their safety appears to be at risk, we may share this information with law enforcement officials to help prevent future occurrences and capture the perpetrator.

Prenatal Exposure to Controlled Substances

Health care professionals are required to report admitted prenatal exposure to controlled substances that are potentially harmful.

In the Event of a Client’s Death

In the event of a client’s death, the spouse or parents of a deceased client have a right to access their child or spouse’s records.

Professional Misconduct

Professional misconduct by a health care professional must be reported by other health care professionals. In cases in which a professional or legal disciplinary meeting is being held regarding the health care professional’s actions, related records may be released in order to substantiate disciplinary concerns.

Judicial or Administrative Proceedings

Health care professionals are required to release records of clients when a court order has been placed. In the event of a court order, only the minimally acceptable amount of information will be revealed. Additionally, if a client files a complaint or lawsuit against anyone affiliated with The Language Lounge; relevant information regarding the client may be disclosed for the purpose of formulating an appropriate defense.

Photocopy Authorization
I permit a photocopy of this consent form as if it were an original executed consent.

initial

Date

MonthDayYear

By signing below, you are attesting to the accuracy of the above statements including all consents and authorizations implied therein. A copy of this agreement is available upon request.

Parent/ Legal guardian signature if child is a minor

Date

MonthDayYear

Speech and Language Survey