TW2 - New Client Information

Please describe any concerns you have about your child's motor skills:*

Can your child ride a bike?

yesno

Please mark your child's love or avoidance of playground equipment:*

	Loves	Likes	Avoids	N/A
Swings
Slides
Sandbox
Climbing equipment
Monkey bars
Running around

Please indicate the age (in months) that your child reached each milestone:*

	Age in months	Never
sat alone
crawled
stood up
walk alone
babble
imitate speech
first word
2 word combination

Any other information you would like to add regarding your child's behavior at the playground?

How many hours per day does your child spend watching TV or playing video games?*

If multiple languages, which language is stronger?

Does your child tolerate:*

	Yes	No
Washing hair
Teeth brushing
Nail cutting
Brushing hair

Please indicate your child's ability to perform the following self help skills:*

	Independent	Needs Assistance	Dependent
Takes off shoes and socks
Putting on shoes and socks
Taking off clothes
Putting on clothes
Fasteners (buttons, zippers)
Eating small foods (ie cheerios)
Eating with a spoon
Eating with a fork
Cutting with a knife
Drinking from a cup
Drinking from a straw
Toileting skills (cleaning himself)

Does your child get dressed in an appropriate time frame?*

yesno

If no, please describe behavior

Does your child seem overly sensitive to noises? (vacuum cleaner, garbage truck, movies, etc.)*

yesno

Does your child have favorite food?*

yesno

If yes, please list some favorite foods.

If your child is being evaluated for feeding, please describe their eating behaviors (how they eat, what they eat, how often & what types of liquids/foods).

Any other information you would like to add regarding your child's self help skills or play behavior at home?

Has your child had a previous speech and language evaluation?*

yesno

If yes, date of previous evaluation

Provided by:

Results/Diagnosis:

Has your child previously had speech and language therapy?*

yesno

If yes, please provide dates of therapy

Provided by:

Results/Diagnosis:

Do any family members have hearing or speech/language difficulties?*

yesno

If yes, please specify relationship to child and what the difficulty was:

What is your child's most frequent means of communication (check all that apply)*

Does your child use words consistently to communicate?*

FrequentlyOccasionallyNever

If so, please provide number of words used consistently

Does your child:*

	Yes	No	Sometimes
Respond to his/her name?
Point to objects when asked?
Follow simple directions?
Get objects from another room when asked?
Point to body parts when asked?
Point to pictures in books when asked?
Answer simple questions?
Point to family members when asked?
Understand prepositions (in, on, under, next to)?
Understand color & size words (red, big/small)?
Engage in pretend/imaginary play?
Socialize/play with other children?
Repeat sounds/words when speaking?
Have difficulty learning/retaining new information?
Have difficulty learning/using new words?

Does he/she have difficulty pronouncing any sounds?*

yesno

If yes, which ones?

What percentage of the time do you feel you understand your child?*

%

Is your child easily frustrated when he/she is not understood?*

yesno

What percentage of the time do you feel others understand your child?*

%

Is your child aware of his/her communication difficulties?*

yesnosometimes

Does your child drool excessively for his/her age?*

yesno

Other areas of general concern (please click all that apply)

NEW CLIENT INFORMATION

ACCESS CODE

CLIENT INFORMATION

BACKGROUND INFORMATION

BIRTH / DEVELOPMENTAL HISTORY

MEDICAL HISTORY

GENERAL INFORMATION