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Speech Therapy Intake Form
Hi there, please fill out and submit this confidential form to help us get to know your child.
29
Questions
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HIPAA
Compliance
1
Child's Name
First Name
Last Name
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2
Date of Birth
-
Date
Year
Month
Day
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3
Please indicate areas of concern:
Speech sounds/Articulation: How they say the sounds
Language: Using and understanding words and sentences to communicate
Fluency: Stuttering
Voice
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4
Describe your child's communication difficulty in your own words:
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5
At what age was the problem first noticed?
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6
How has the problem changed since that time?
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7
Has your child ever been assessed for speech/language concerns?
YES
NO
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8
Has your child received any prior speech/language therapy?
YES
NO
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9
Information about prior speech/language therapy?
If so, where
By whom?
For how long?
Focus of treatment/results
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10
Have any other family members had speech/language problems?
YES
NO
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11
Family history of speech/language problems: Please describe the relationship & nature of the problem, if any.
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12
My child communicates through
Please select the highest level
Whining/Crying
Gestures
Sign Language
Pictures/speech generating device
Single Words
Multiple Word Sentences
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13
Does your child demonstrate frustration when he/she is not understood?
YES
NO
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14
Does your child engage in eye contact during communication?
YES
NO
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15
If your child is in school, are there concerns about academic performance?
YES
NO
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16
Does your child like school?
YES
NO
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17
How much of your child's speech do you understand?
10% or less
11-24%
25-50%
51-74%
75-100%
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18
How much of your child's speech is understood by others?
10% or less
11-24%
25-50%
51-74%
75-100%
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19
Are there any error patterns you have noticed specifically?
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20
When did your child first start stuttering?
Be as specific as possible.
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21
What did the stuttering sound like when it first began?
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22
Describe how your child's speech sounds now
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23
What seems to help when your child is stuttering?
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24
Does your child demonstrate:
Check all that apply
Awareness of stuttering
Physical tension during moments of stuttering
Frustration about speaking
Complaints that he/she "can't talk"
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25
Has your child ever been teased about stuttering?
YES
NO
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26
Is there a history of stuttering in the family?
YES
NO
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27
Rate how often your child is able to speak FLUENTLY in the following situations
Always
Almost Always
Sometimes
Rarely
Never
At Home
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
At School
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
In the Community
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
At Home
At School
In the Community
Always
Row 0, Column 0
Almost Always
Row 0, Column 1
Sometimes
Row 0, Column 2
Rarely
Row 0, Column 3
Never
Row 0, Column 4
Always
Row 1, Column 0
Almost Always
Row 1, Column 1
Sometimes
Row 1, Column 2
Rarely
Row 1, Column 3
Never
Row 1, Column 4
Always
Row 2, Column 0
Almost Always
Row 2, Column 1
Sometimes
Row 2, Column 2
Rarely
Row 2, Column 3
Never
Row 2, Column 4
1
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28
Rate how often your child is able to speak freely, regardless of fluency.
Always
Almost always
Sometimes
Rarely
Never
At Home
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
At School
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
In the Community
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
At Home
At School
In the Community
Always
Row 0, Column 0
Almost always
Row 0, Column 1
Sometimes
Row 0, Column 2
Rarely
Row 0, Column 3
Never
Row 0, Column 4
Always
Row 1, Column 0
Almost always
Row 1, Column 1
Sometimes
Row 1, Column 2
Rarely
Row 1, Column 3
Never
Row 1, Column 4
Always
Row 2, Column 0
Almost always
Row 2, Column 1
Sometimes
Row 2, Column 2
Rarely
Row 2, Column 3
Never
Row 2, Column 4
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29
Phone Number of Parent/Guardian
Please enter a valid phone number.
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