Speech Therapy Marin

Intake Form

ico_pdfSpeech Therapy Marin has an individualized and holistic approach in serving clients.  Please take your time in filling out this “inate form”. The form is also available as a PDF. If you have questions please contact me. Thank you.

Child's Last Name (required)

Child's First Name (required)

Child's Date of Birth

Child's Grade

Caregiver (check after appropriate label)

Caregiver’s Last, First Name

Caregiver’s Email

Caregiver's Phone

Best Time to Contact

Caregiver’s Home Address:

Child’s Home Address (or same as above):

Child's Current School

Child's Gender:

Reason for referral to speech therapy?


Concerns regarding child’s lack of academic and/or social/emotional progress/development?

Child’s age when you first noticed problems?

What educational question(s) would you like the assessment to answer?

Developmental and Family History

Child’s Physician:

Physician Address

Physician Phone:

Date of last:
physical examination
hearing screening
vision screening

Member(s) of Household

Name | Relationship | Age | Occupation
(one member's info per line please)

Language(s) spoken at home

Language preferred by child

Length of Pregnancy   Birth Weight

Describe pre- and postnatal maternal health and infant’s health at birth and during first month:

Is there anyone in your immediate or extended family who has had learning problems? If yes, who? Describe the problems they had in school.

How old was child when he or she began to talk?
Single words?
Sentences?

How old was the child when he or she crawled?
Walked?

Current or chronic health problems (e.g., fatigue, asthma, allergies, seizures, etc.)

Is child currently on medication? If yes, type of medication and for what ailment?

Are there nutritional concerns?

History of illnesses, accidents, hospitalizations:

Speech/Language

(click here for "developmental norms" chart to determine if errors are developmental or delayed)

Articulation (Sound Production):
Late/Missing/Distorted speech sounds?

Percentage of overall intelligibility?
Familiar listener?
Unfamiliar listener?

Receptive Language (Comprehension) strengths/concerns

Expressive Language strengths/concerns

Pragmatic (Social/Emotional) Language strengths/concerns

Motor Development: (coordination, gross motor and fine motor activities)

Hearing/ear problems:
Vision or eye problems:
If yes, explain:

Does child need to wear glasses or a hearing aid?

Sleep Disturbances?

Toilet Problems?

Weight Problem?

Nervous Habits?

Describe how your child spends his/her time at home.
(How do they play, interests, how active, play alone, with others, both?)

 


Describe how your child interacts and communicates with siblings, other family members, and with peers. Does your child have difficulty in building or maintaining relationships? Is he/she friendly, active, aggressive, quiet? Does he/she get angry easily or have tantrums?

Describe your child’s adaptive behaviors i.e., self-care, responsibilities around the home, independent functioning in the community. What does he/she do independently? Dress/undress? Bathroom use? Use of utensils to eat? Behavior in public?

Describe any personal traumas or emotional upsets (if any) that appear to be adversely impacting your child (persistent fears, feelings, or behaviors; development of physical symptoms, and/or emotional concerns.)

What techniques or methods have been attempted/implemented in your stated areas of concern?

Prior Assessments

Has your child been tested by another agency?

If yes, please provide the contact information of the person/agency who did the testing.
Name/Agency:
Agency Address

Agency Phone:   Agency Email:

*Please provide a copy of any assessment report you have*

This will ensure that your child is not over assessed and facilitates the therapeutic process.

 


Thank you for taking the time to send me your child's personal information. It helps me to determine the appropriate level of therapeutic intervention and sensitivity to each individual I work with.