Speech Language Intake Form

Please provide as much detail as possible as you fill out this form. Complete information will help evaluating therapist select the best materials for assessment. Please provide details in the “Comments” section if you answered YES to any questions.

BIOGRAPHICAL

Child's name*

Date of Birth*

Person Providing Information*

Relationship to child*

Date Form Completed*

CONCERNS

When did you first become concerned with your child’s speech and language skills?*

Is your child aware of or frustrated by any speech/language difficulties?*

Yes
No

Comments

Have your child’s communication skills, including verbal and non-verbal communication, changed over the past few months?*

Yes
No

Comments

FAMILY HISTORY

Does your child have family members with any of the following? If YES, please provide details in the comments.

Hearing loss
Developmental delay
Speech (articulation) or language
Autism Spectrum Disorder
ADHD
Reading or learning disability
Stuttering
Other: please provide more detail in comments

Comments

HEARING

Do you have concerns about your child’s hearing?*

Yes
No

Comments

Has your child been evaluated by an audiologist in the last six months? If yes, please provide when and where in the comments. Please provide a copy of results at the evaluation.*

Yes
No

Comments

Has your child received services for hearing loss?*

Yes
No

Comments

Does your child wear/use hearing devices (e.g. hearing aid, cochlear implant, FM system)?*

Yes
No

Comments

If yes, what type and how long has your child worn hearing device(s)?

If cochlear implant, provide date of surgery and date of activation.

LANGUAGE COMPREHENSION

My child responds to their own name.*

Yes
Sometimes
No
N/A

My child understands what I am saying.*

Yes
Sometimes
No
N/A

My child follows simple directions. (e.g. Come here. Shut the door.)*

Yes
Sometimes
No
N/A

My child responds correctly to yes/no questions.*

Yes
Sometimes
No
N/A

My child responds correctly to who/ what/ where questions.*

Yes
Sometimes
No
N/A

My child responds correctly to when/why/how questions.*

Yes
Sometimes
No
N/A

My child retrieves/points to common objects upon request (e.g. ball, cup, shoe)*

Yes
Sometimes
No
N/A

My child looks at a toy/object when I point across the room.*

Yes
Sometimes
No
N/A

My child tries to get me to notice interesting toys/objects.*

Yes
Sometimes
No
N/A

Comments

LANGUAGE EXPRESSION

Which of the following describes how your child lets you know what they want/need? Please provide details in the comments.

Looking
Crying
Pointing
Voicing / gruning
Gestures / facial expressions
Single words / approximation
2-3 word combinations
Sentences
Augmentative Alternative Communication (AAC) = pictures, device, iPad, signing

Please provide details about system

NASOPHARYNGEAL, ORAL-FACIAL, FEEDING

Does your child require supplementary oxygen?*

Yes
No

Comments

Has your child had tonsils and/or adenoids removed?*

Yes
No

Comments

Has your child had a tongue, lip, or cheek release to free tethered tissue?*

Yes
No

Comments

What is your child’s mouth posture during rest/sleep?*

Open
Closed

Comments

Please check any that apply to your child and provide details in the comments.*

Breastfed
Bottle-fed
Tube-fed
Chews non-food objects frequently
Used (uses) a pacifier
Sucks fingers and/or thumb
Grinds teeth
Bites inappropriately

Does your child accept a variety (20+) foods including fruits and vegetables?*

Yes
No

Comments

Does your child have a history of reflux/spitting up?*

Yes
No

Comments

ARTICULATION (SPEECH), STUTTERING, VOICE

My child’s speech is easy to understand all the time.*

Yes
No
N/A

My child’s speech is difficult for parents and close family members to understand.*

Yes
No
N/A

The percentage of time that I understand my child’s speech:*

Please enter a number from 0 to 100.

My child’s speech is difficult for others to understand.*

Yes
No
N/A

The percentage of time that others understand my child’s speech:*

Please enter a number from 0 to 100.

My child has difficulty with sounds getting stuck or repeating syllables (stutters).*

Yes
No
N/A

My child’s voice sounds like peers of similar age and gender.*

Yes
No
N/A

Comments

PLAY SKILLS

My child engages in pretend play with toys.*

Yes
No

My child plays with toys.*

Appropriately
Selectively

My child prefers to play alone.*

Yes
No

My child has opportunities to play with similar-aged peers.*

Yes
No

My child likes music.*

Yes
No

Comments

Please describe your child’s preferred toys, activities, games, and/or books.*

Please describe what your child is passionate/feels strongly about.*

BEHAVIORAL PRESENTATION, SENSORIMOTOR

Please check any that apply to your child and provide details in the comments.*

Comments

Please check any that your child is particularly sensitive/has a strong reaction to and describe in the comments.

Touch
Noise
Taste
Smell
Vision

Comments

Please check any that apply to your child and provide details in the comments.

Uses too much force to do things
Bangs into things on purpose
Engages in rough and tumble play
Avoids active physical games involving running, jumping

Comments

LITERACY SKILLS (PRE-READING, READING)

Does your child rhyme words?*

Yes
No
N/A

Does your child understand letter sounds?*

Yes
No
N/A

Does your child enjoy when your read to them?*

Yes
No
N/A

Does your child read?*

Yes
No
N/A

Can your child understand what is read?*

Yes
No
N/A

Please describe any concerns you have about your child’s reading.

PRAGMATIC/SOCIAL LANGUAGE

Does your child understand and use turn-taking?*

Yes
No
N/A

Can your child remain on-topic in conversations?*

Yes
No
N/A

Does your child engage in eye-contact as you would expect?*

Yes
No
N/A

Does your child engage in conversations as you would expect for their age?*

Yes
No
N/A

Comments

Phone

This field is for validation purposes and should be left unchanged.