TLS Speech &Language Intake Form

Speech & Language History Form Thank you for taking a few minutes to complete this history form. All information is held strictest confidence. At no given point is information disclosed or shared without client’s written consent.

Child's Name

First NameMiddle NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Home Phone

Area CodePhone Number

Child's Birth Date

MonthDayYear

Parent Name

First NameLast Name

Parent's Email

Parent Cell Phone

Format: (000) 000-0000.

Parent Occupation

Parent #2 Name

First NameLast Name

Parent E-mail

Parent Cell Phone

Format: (000) 000-0000.

Parent Occupation

Marital Status:

Who referred you?

Child's Allergies

Child's Medications

Why are you seeking a speech and/or language evaluation?

Pregnancy & Birth Information

Pregnancy

Pregnancy Complications please explain:

Length of pregnancy

Delivery Was:

Birth weigh: lbs oz*

Please explain any complication during delivery or immediately following birth:

Medical Information

List any Educational/Neurological/ Psychological evaluations - when, where (professional) and findings

List any PHYSICAL THERAPY or OCCUPATIONAL THERAPY evaluations - when, where (professional) and findings

List any AUDIOLOGICAL or HEARING testing - when, where and findings

Please check if your child has experienced any of the following:

List illnesses, accidents or operations your child has had:

Developmental Motor History

At what age ( in months) did your child first?

Roll over

Sit Up

Crawl

Stand alone

Walk

Smile

Dress Self

Toilet trained

Developmental Speech History

At what age ( in months) did your child first?

Babble

Say 1st word

Combined 2 words

Produce sentences

Currently, does your child (select all that apply)

Feeding

Please select all that apply to your child during mealtime?

How was your child fed during infancy? Breast? Bottle? How long did your child breast and/or bottle feed? If fed by abottle, what formula? Any difficulties with breast or bottle feeding?

Previous history? :

Is there additional relevant information or concerns we should know about your child's feeding?

Play Skills / Social Skills

Check all that apply regarding your child's play skills:

If applicable : check all that apply:

Home Environment

Who lives at home with your child? (Name, Ages, Relationship to child):

Schedule: Please describe a 24-hour time period for your child (i.e. from the time they wake up, until they go to bed ,including daily routines, how they sleep):

Primary language(s) spoken at home?

Educational Information

Child's School Name & Grade

What concerns do you have about your child's speech and language?

Describe your child's personality listing his/her strengths and weaknesses.

What activities and hobbies does your child enjoy?

Do most people understand your child?

Other

My child has difficulty:

Check all that apply

Does anyone in your family have similar speech or language difficulties?

What else would you like me to know about your child?