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? Occasionally Never Frequently What 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? Yes No Do you have difficulty understanding your child? Yes No Do other people have difficulty understanding your child? Yes No Does your child feel frustrated by an inability to communicate? Yes No Do you think your child stutters? Yes No Has your child had feeding or swallowing difficulties? Yes No How 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? Yes No If yes, please explain:Has your child had any problems learning to write? Yes No If yes, please explain:
