Date form completed (mm/dd/yy):
Child's First Name:
Child's Last Name:
Child's DOB (mm/dd/yy):
Guardian's First Name:
Guardian's Last Name:
Address:
Address cont.
City:
State/Province:
Zip/Postal Code:
Home Phone:
Work Phone:
What are your concerns for the child's speech-language development?
Does a pediatrician have any concerns regarding the child's speech-language development?
How does the child communicate his/her wants and needs?
Can familiar adults understand the child's communication?
Can unfamiliar adults understand the child's communication?
Does the child stutter?
Does the child attend daycare, school or preschool?
If so, where does the child attend
What are the child's teacher's concerns for the child's speech-language development?
How is the child typically disciplined?
How does the child play with other children their age?
Describe any difficulties the child has chewing and swallowing foods.
Describe any difficulties with the pregnancy, labor or delivery.
Describe any difficulties after birth.
What major childhood illnesses has the child had?
Has the child been hospitalized?
Has the child had any ear infections?
Has the child had any seizures?
What medications is the child on?
Is the child followed by any medical specialists?
What were the results of the child's last hearing evaluation?
What were the results of the child's last vision examination?
Did the child learn to walk and talk on time?
What languages are the child exposed to?
Is there any family history of speech-language delay?
Has your child received any special services prior to being seen by Play Therapy?
If therapy is needed, do you have a preferred day and/or time you would like the child to be scheduled?
