Intake Form Fill out some info, and we will be in touch shortly! Child's Full Name * First Name Last Name Child's Date of Birth * MM DD YYYY Gender Male Female Other Parent/Guardian Names * First Name Last Name Relationship to Child * Address Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Phone * (###) ### #### What services are you interested in? * Speech Evaluation Speech Services Parent Training Speech Screener How did you hear about us? * Google Referral Day Care Other Medical & Developmental History Primary Diagnosis Please be sure to list out other diagnoses if applicable Current Medications (if any) Does your child have any allergies? * Yes No Is your child currently receiving other therapy services? * Yes No Does your child have an IEP (Individualized Education Plan)? * Yes No Any family history of speech/language delay? * Yes No Any history of hearing or vision concerns? * Yes No Speech & Language Concerns Please describe your primary concerns regarding your child's communication. * Has your child received a prior speech/language evaluation? * Yes No What language(s) does your child speak at home? * How does your child currently communicate? * Words Gestures Sign Language Pictures Communication Device Other Does your child have difficulty with: Articulation (pronouncing sounds) Understanding language Expressing themselves Social communication (e.g., engaging in conversation, making friends) Stuttering Other Educational Information: School Name Grade Level * Does your child have an IEP (Individualized Education Plan)? * Yes No Any additional school concerns? Family & Social History Who lives in the household? Any family history of speech/language delay? * Yes No Does your child enjoy interacting with peers? * Yes No Does your child enjoy interacting with peers? * Yes No Any behavioral concerns? * What are your goals for speech therapy? * Will your child be able to engage in virtual speech therapy? * Yes No Any Additional Information? Thank you for completing this form! Our team will review the information and contact your shortly to discuss the next steps.
