Date - must be mm/dd/yyyy format * Required MM slash DD slash YYYY Patient's First Name * Required Patient's Last Name * Required Date of Birth - must be mm/dd/yyyy format * Required MM slash DD slash YYYY Address * 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 Preferred Contact Method * Required Phone Email 1st Parent/Guardian Name * Required Address * 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 2nd Parent/Guardian Name * Required Address (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 Phone * RequiredEmail * Required Referring Person * Required Reason for Referral * RequiredHas the child had any previous speech/language therapy? * Required Yes No Is the child receiving speech/language therapy at the present time? * Required Yes No Developmental HistoryThe patients mother have any difficulties during pregnancy or child birth? * Required No Yes The the best of your recollection, at what age was the child able to hold up had while lying on stomach * Required The the best of your recollection, at what age was the child able to sit unsupported and walk unassisted * Required The the best of your recollection, at what age was the child able to feed self with a spoon, dress self * Required At what age was toilet training completed? * Required What type of cup does your child use? Can he/she drink from a straw? Did child suck thumb or use pacifier? Yes No If so, at what age did they stop? Has the child ever had a hearing evaluation? Yes No Does your child wear glasses? Yes No Speech & 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 Short Phrases Sounds Single Words Is your child able to understand... Gestures Words Short Phrases Sentences At what age did your child: Imitate sounds, first words At what age did your child: Tell a simple story accurately At what age did your child: Put 2-3 words together, talk in full sentences What 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? What school does your child attend? What subjects does he/she find difficult? Specialized Speech and Language Therapy Call Now
