Speech & Language Therapy Intake Form Parent/Guardian First Name:*Parent/Guardian Last Name:*Primary Phone Number:*Alternate Phone NumberEmail Address:* Child’s Name:* Describe your child’s speech/language problem in your own words:At what age was this problem first noticed?Who first noticed the problem?How has the problem changed since that time?Does your child use speech?OccasionallyNeverFrequentlyWhat is the current communication style(s) used by your child? Check all that apply. Non-word vocalizations Single words Words and gestures Short phrases Word combinations Full sentences Gestures and/or pointing only Estimate size of expressive vocabulary (number of words child spontaneously uses):Is correct word order used in sentences/phrases?YesNoDo you have difficulty understanding your child?YesNoDo other people have difficulty understanding your child?YesNoDoes your child feel frustrated by an inability to communicate?YesNoDo you think your child stutters?YesNoHas your child had feeding or swallowing difficulties?YesNoHow well does your child understand what is being said to him/her (ability to follow directions and understand meaning of words)?Has your child had any problems learning to read?YesNoIf yes, please explain:Has your child had any problems learning to write?YesNoIf yes, please explain:
