Child's First Name * RequiredChild's Last Name * RequiredSex * RequiredSexMaleFemaleAddress * Required Street Address Address Line 2 City StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone * RequiredEmail * Required Can we contact you via email? * RequiredYesNo1st Parent/Guardian Name * RequiredOccupation * RequiredAddress * Required Street Address Address Line 2 City StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code 2nd Parent/Guardian Name * RequiredOccupationAddress (if different) Street Address Address Line 2 City StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Name of Child's SchoolHas the child had any previous speech/language therapy? * RequiredYesNoIs the child receiving speech/language therapy at the present time? * RequiredYesNoDevelopmental HistoryThe the best of your recollection, at what age was the child able to hold up head while lying on stomach * RequiredThe the best of your recollection, at what age was the child able to sit unsupported and walk unassisted * RequiredThe the best of your recollection, at what age was the child able to feed self with a spoon, dress self * RequiredAt what age was toilet training completed? * RequiredWhat type of cup does your child use?Can he/she drink from a straw?Did child suck thumb or use pacifier?YesNoIf so, at what age did they stop?Has the child ever had a hearing evaluation?YesNoDoes your child wear glasses?YesNoSpeech & Language HistoryAre you aware of any factors (e.g., physical, emotional, or environmental) that might have contributed to his/her communication difficulty?Please describe any developmental issues in addition to the communication problem your child may have.Approx. how many words does your child consistently use?How does your child usually communicate? Pointing Gestsures Short Phrases Sounds Single Words Sentences Is your child able to understand... Gestures Words Short Phrases Sentences At what age did your child: Imitate sounds, first wordsAt what age did your child: Tell a simple story accuratelyAt what age did your child: Put 2-3 words together, talk in full sentencesWhat is the primary language spoken at home?Are there other languages spoken at home?Does this child have playmates of his/her own age?Is your child enrolled in any play groups?Do they get along with other children?What are their favorite activities or games?Does he/she play contentedly by himself/herself?Does he/she prefer to be with children or adults?Please describe your child's personality.What is his/her favorite toy?Any concerns about behavior or social skills?School HistoryAt what age did schooling begin?In what grade is the child enrolled?Does the child like school?What subjects does he/she find difficult? This iframe contains the logic required to handle Ajax powered Gravity Forms. Specialized Speech and Language Therapy Call Now
