Child Intake Form / History

Today’s Date:

Client Name:

Nickname:

Date of Birth:

Age:

Pronouns:

Diagnosis (if known):

Address:

City, State, Zip:

Phone #1:

Cell Home Work Other

Phone #2:

Cell Home Work Other

Phone #3:

Cell Home Work Other

Email #1:

Email #2:

Emergency Contact Name:

Emergency Contact Relationship to Child:

Emergency Contact (Information):

Client’s Physician:

Physician Phone Number:

Physician Address:

Other Physicians / Specialists Involved In Care:

Referring Physician:

Phone Number:

Physician Address:

Secondary Physician:

Phone Number:

Physician Address:

How did you hear about [Private Practice / Private Practitioner Name]?

Family Background

Parent / Guardian 1 Name:

Best Contact Information:

Parent / Guardian 2 Name:

Best Contact Information:

What adults does the child live with? Check all that apply:

Other:

Does the child have siblings or are there other siblings in the home?
Child 1 Name:

Age:

Speech Issues:

Child 2 Name:

Age:

Speech Issues:

Child 3 Name:

Age:

Speech Issues:

Language(s) spoken in the home:

Who speaks the other language(s)?

Describe the child’s use/understanding of the language(s):

Is there anything additional you would like to share about the family / home environment?

Evaluation

Briefly describe why you’re seeking an evaluation by a speech-language pathologist at this time:

What are you expecting out of this evaluation / meeting?

Has the child had a previous speech, language or feeding evaluation / treatment?

Yes No

By whom:

When

Describe the results:

Describe in your own words the nature of your concerns about the child’s development and/or the primary referral reasons:

At what age did you first notice the problem?

How do the child’s communication difficulties impact the family?

Medical History

Describe any pertinent information about the child’s medical history (surgeries, diagnoses, etc.) as well as when they were diagnosed and by whom:

Birth Parent’s Health During Pregnancy:

Were there any infections or illnesses?

Yes No

If so, please describe:

Was there any stress during the pregnancy?

Yes No

If so, please describe:

Were there any complications during labor or delivery?

Yes No

If so, please describe:

What was the birth parent’s age at the time of delivery?

Child’s Health:
How many weeks gestation was the child born? (40 weeks is typical)

The child was
_____ lbs

____oz

and _______ inches at birth

How was the child delivered?

Vaginally Cesarean Section

Please describe any complications or concerns during labor or delivery:

Please describe any of the selected above:

Is the child up to date with immunizations:

Yes No

Please describe:

Has the child ever had surgery?

Yes No

Please describe:

Has the child ever been hospitalized:

Yes No

Please describe:

Has the child ever been in a serious accident?

Yes No

Please describe:

Does the child have a chronic illness?

Yes No

Please describe:

Is the child currently on any medications? If so, please list medication name and reason for medication:
Medication 1:

Medication 2:

Medication 3:

Medication 4:

Does the child have any known allergies?

Yes No

Please describe:

Does the child currently use any equipment? (communication device, walker, etc.) If so, please describe:

Does the child have a history of ear infections, tubes, etc. or use hearing aids?

Yes No

Please describe:

Does the child have any known hearing loss?

Yes No

Please describe:

If you have any concerns about the child’s hearing, please describe:

Describe the child’s current health status:

Is the child currently receiving any of the following services? If yes, please list the person’s name and last date of service.

Developmental Pediatrician

Name:

Neurologist

Name:

PT

Name:

OT

Name:

SLP

Name:

Behavioral Therapist

Name:

Educational Consultant

Name:

Psychologist / Psychiatrist

Name:

Vision Therapist

Name:

Other:

Developmental History

At what age did the child do the following:

Sit alone:

Stood Up:

Made Sounds:

Combined Words:

Fed Self:

Toilet Trained:

Crawl:

Walk:

First Word:

Sentences:

Understood by Others:

Dressed Self:

Does the child do any of the following:

Please describe any of the above:

Does the child produce sentences of the following length:

2 words 3 words 4 words 5+ words

What percentage of the child’s speech do you understand?

How well do people outside of the family understand their speech?

If the child is not using words, how do they communicate?

Other difficulties:

Please describe any of the above:

Has the child experienced any difficulty with feeding or swallowing?

Yes No

Educational History

Is the child currently enrolled in daycare/ school:

Yes No

What is the name of the program?

What day(s) do they attend?

What is their grade level:

Type of classroom:

If they receive any accommodations, please describe:

Please describe any educational difficulties or learning challenges that this child has faced:

Describe how the child interacts with parents, siblings, or other family members:

Please describe the communication difficulties the child faces in the home environment:

Describe any significant events or changes within the home:

What are the child’s strengths?

What are the child’s weaknesses?

What are the child’s favorite activities?

Does the child participate in any community activities (ex. play groups, sports, etc.) and how is their communication / behavior?

Does the child become easily frustrated with certain activities? If so, please explain:

Describe how the child interacts with other children:

What are your goals for the child over the next 6 months?

What are your goals for the child over the next 5 years?

Is there anything else that is important for us to know about the child?

Person filling out the form:

Relationship to the child:

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