Client Intake Form-LAF Clinic
Client Name
First Name
Last Name
Client Birthdate
-
Month
-
Day
Year
Date
Client's current age
Gender
Client's address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Referred by:
Mother's Name
First Name
Last Name
Mother's email address
example@example.com
Mother's phone number
Please enter a valid phone number.
Father's Name
First Name
Last Name
Father's email address
example@example.com
Father's phone number
Please enter a valid phone number.
Email address
example@example.com
Phone Number
Please enter a valid phone number.
Date
-
Month
-
Day
Year
Date
List the name, age and relationship other all persons living in the home. Example: Sam, 8, brother
Family Physician
I believe my child has difficulty with (select all that apply)
Speech (articulation)
Language
Voice
Fluency
Hearing
Other
Description of Problem? When was problem first noticed
What do you think caused the problem?
What has been done to correct it?
How does the child seem to feel about their problem?
Does any other family member have a speech or hearing problem? If yes, state the nature of the problem and relationship to the child.
Describe health of mother during pregnancy
Describe any diseases, accidents, drugs, x ray treatment of mother during pregnancy.
Exposure to any infectious diseases during pregnancy?
Which pregnancy was this child?
Full term pregnancy?
Length of labor?
Was delivery normal?
Child's weight and condition at birth
Describe any birth problems
Was child's development normal for sitting, standing, walking, etc.?
Describe any health or feeding problems during early childhood.
When did the child begin to babble or coo?
When did the child speak first words? Sentences?
How does child make wants and needs known?
Has the child's speech changed recently? If so, how?
Does the child repeat your questions instead of answering them?
Health History: (Give age and severity of the illnesses your child has had)
Age
Describe Illness
Measles
Mumps
Chicken Pox
Pneumonia
Allergies
Tonsilitis
Ear infections
Fainting
Seizures
Diabetes
High fever
Visual
Ashthma
Frequent Colds
Thyroid trouble
Paralysis
Heart condition
Other
What operations and/or serious accidents has the child had? (include dates)
What medication, if any, does the child receive?
School
Response
Current school
Grade
Teacher
What is child's attitude toward school
Describe any school difficulties
Has the child ever had an intelligence test? (Explain)
How would you describe the child's personality?
How does the child respond to people?
Is the child hard to manage?
Does the child eat and sleep well?
How is the child punished?
Has the child ever experienced a severe shock or fright? If so, explain.
Hearing (complete if you think your child has a hearing problem)
Response
What makes you think your child has a hearing problem?
How old was the child when you realized there was a hearing problem?
Does he pick or pull/his/her ears?
Does your child wear hearing aids? (Left ear, right ear, both ears)
Upload any relevant files (IEPs, Evaluation reports, etc.)
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