Child Intake Form

Dear Parent or Guardian,

Please make sure you have at least 20 minutes available to complete this form. Please email copies of the following documents to your therapist or to lanag@tplspeech.com or fax them to (503) 893-3063:

Speech-language evaluations, hearing tests, recent medical physical, and/or relevant medical evaluations (e.g., autism diagnosis).
Previous speech therapy progress reports, IEPs, IFSPs.

PLEASE RETURN THIS INFORMATION TO YOUR THERAPIST BEFORE YOUR INITIAL APPOINTMENT

***Active Military/Veterans: With proof of service, we offer a free evaluation to active duty/veteran families. Please let your therapist know if you qualify.***

Child's Name *

First Name Last Name

Child's Date of Birth *

Date

Gender *

Guardian/Parent 1 - this will be the primary contact in our system *

First Name Last Name

Phone Number *

Please enter a valid phone number.

Guardian/Parent 1 email where you will receive a password-protected copy of this form. Please note down the password for your records: 1TPLspeech!: *

example@example.com

Yes, I give consent for communication via text (eg. appointment reminders) and secure email regarding treatment and ongoing care NO, I DO NOT give consent for communication via text (eg. appointment reminders) and secure email regarding treatment and ongoing care.*

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Guardian/Parent 2

First Name Address

Phone Number

Please enter a valid phone number.

Email

example@example.com

Name of School (if attending)

Grade

What is your availability for ongoing weekly speech therapy appointments? For example: Monday all day, Tuesdays after 3pm. The greater your availability, the easier it will be to ensure we are able to offer you an appointment. *

Insurance Carrier: *

Membership Number *

Does your child have Oregon Health Plan? *

Yes No

If yes, what is the OHP membership number? *

Clinic Name *

Pediatrician's Name

Clinic Phone Number

Please enter a valid phone number.

Clinic Address

What are your main concerns? Include when the problem was first noticed and who noticed it.

How does your child react to being misunderstood or when unable to communicate? (click all that apply)

Tries again/revises Becomes angry/frustrated Gives up Doesn't notice Other

Has your child’s physician noticed these concerns? If yes, what were the recommendations?

List all other services your child has received, including counseling; psychiatry; physical, occupational, or speech therapy.

	Type of Service	Dates/Age	Name of Provider

With whom does your child live? (check all that apply)

Biological Parent(s) Adoptive Parent(s) Grandparents Legal Guardian(s) Sibling(s) Other

List all family members who live in the same home as your child.

	Name	Age	Relation to Child

List any family pets (name/type of animal)

Are there family circumstances that would be helpful to share with your child's therapist? (e.g., custody arrangements)

Are there any other languages spoken in the home? If yes, which language(s) and how often? Has your child ever lived in a country other than USA? If yes, for how long?

Do any other family members have speech, language, or related difficulties or disorders?(e.g., ADHD, autism)

	Relation to Child	Related Diagnosis/Disoder

Describe pregnancy, including any complications.

Describe labor/delivery, including any complications.

Birth Place (hospital, birth center)

Gestational Age (in weeks)

Birth Weight

Birth Length

Stay In NICU?

If in NICU, for how long?

Were there any complications after birth or during the first few weeks?

Difficulty breathing Difficulty Feeding Birth Defect Jaundice Seizures Other

Did your child pass their last hearing test? *

When was your child's hearing tested? (it is recommended that hearing be tested in the past year, especially if there is history of ear infections) *

Where was your child's hearing tested? *

Describe any serious illnesses, injuries, or medical procedures your child has experienced.

List any environmental or food allergies.

List any routine medications your child is currently taking.

Describe any other conditions or diagnoses identified by your child’s doctor or other professionals.

At what age did your child begin to:

	Age (months/years)
babble (bababa)
jargon (bada bama)
say first words
2-word combination
3-word combination
sentences
reading letters
reading words
reading sentences
writing letters
writing words
writing sentences

Who understands your child’s speech, and how much do they understand? 25% = 1 out of 4 words understood 50% = 2 out of 4 words understood 75% = 3 out of 4 words understood 100% = 4 out of 4 words understood

	parents	siblings	peers	teachers	extended family	strangers
0%
25%
50%
75%
100%

Has your child’s speech-language been evaluated before? If yes, please note the place and summarize the findings. Please send us the report(s) if you have access to them or bring them to your first appointment. *

What are a few specific goals or skills you would like your child to attain in speech therapy?

Is your child aware of his/her communication difficulties? Do you wish to share information with your child, such as goals or diagnosis?

Favorite books are:

Favorite movies, shows are:

Favorite foods are:

Preferred activities, hobbies, or special interests are:

Strengths and personality traits are:

Please list anything else that you feel is important to know for the purposes of evaluating/providing services to your child:

How did you learn about us? *

Name of person providing information *

First Name Last Name

Signature *

Clear

Child Intake Form

Child's Insurance Information

Pediatrician Information

Child's Health Background

Child's Speech and Language Development

Child's Strengths and Favorites