Your Name* Phone*Child's Name* Birthday* MM slash DD slash YYYY Diagnosis:*School: Grade: Teacher: What is your biggest concern with your child?*Does your child current or has he/she previously received any therapy services? If current, please list name and email address:*Medical HistorySignificant birth history?*Siblings? Please include names and ages (list any previous therapies received):*Significant surgical history?*Significant recurrent health problems (including asthma, ear infections, etc.)?*Current medications?*Primary language?* Community activities (including sports teams, classes, park district programs, play groups, church groups, etc)?*Is your child exposed to languages other than the primary language?*Speech-Language Developmental Milestones:Please tell us approximate age when your childBabbled* Said first word* Put words together* Spoke in sentences* Does your child understands what is spoken to her/him? (Comment on his ability to follow directions, recognize pictures, answer what, where, yes/no questions, responses to reading books etc.)*How does your child currently communicate? (Comment on vocabulary, pointing, gestures, sentence use, and ability to participate in conversation)*Are you concerned about your child’s speech intelligibility or ability to enunciate speech sounds?*If your child is non-verbal, then is he/she using a communication device? If yes then which one?*Are you concerned about your child’s behavior? (e.g. poor eye contact, easily distracted, difficulty attending to activities, aggression, withdrawn, self-abusive behaviors etc.)*If your child is school age, are there any academic concerns? Difficulties with specific subjects?*Do you have any social concerns about your school going child?*What would like to achieve from today’s evaluation? How can we help?*
