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Child Intake Form / History
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Client Name
*
Nickname
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Date of Birth
*
Age
*
Gender
*
Male
Female
Prefer Not To Respond
Diagnosis (If Known)
Parent(s) / Guardians
Address
*
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone
Email
*
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Emergency Contact Name
Emergency Contact Relationship to Child
Emergency Contact (Information)
Client’s Physician (Information)
Other Physicians / Specialists Involved In Care
How did you hear about Branched Out Therapy, Inc.?
Family Background
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Parent 1 Name
Occupation
Age
Education Level
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Parent 2 Name
Occupation
Age
Education Level
Marital Status
Single
Married
Divorced
Separated
Widowed
What Adults Does The Child Live With? Check All That Apply
Birth Parent(s)
Adoptive Parent(s)
Foster Parent(s)
Grandparent(s)
Both Parents
Step Parent
Other
Does The Child Have Siblings or Are There Other Siblings In The Home? List All Speech Concerns for Each Sibling
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Language(s) Spoken In The Home
Who Speaks The Other Language(s)?
Describe The Child's Use/Understanding of The Language(s)
Is There Anything Additional You Would Like To Share About The Family / Home Environment?
Evaluation
Briefly Describe Why You’re Seeking An Evaluation By A Speech-Language Pathologist At This Time
What Are You Expecting Out of This Evaluation / Meeting?
Has The Child Had A Previous Speech, Language or Feeding Evaluation / Treatment?
Yes
No
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By Whom?
When?
Describe The Results
Please Upload Copies of Any Previous Evaluations, Progress Reports, or IEP’s. You May Also Bring Them In At Our First Meeting.
Click or drag files to this area to upload.
You can upload up to 3 files.
Describe In Your Own Words The Nature of Your Concerns About The Child’s Development and/or The Primary Referral Reasons
At What Age Did You First Notice The Problem?
How Do The Child’s Communication Difficulties Impact The Family?
If Anyone Else In The Family Has A Speech or Language Diagnosis, Please Describe It
Is The Child Aware of or Frustrated By Their Communication Difficulties?
Medical History
Describe Any Pertinent Information About The Child's Medical History (Surgeries, Diagnoses, Etc.) As Well As When They Were Diagnosed And By Whom
Mother’s Health During Pregnancy
Were There Any Infections or Illnesses?
Yes
No
Please Describe
Was There Any Stress During The Pregnancy?
Yes
No
Please Describe
Were There Any Complications During Labor or Delivery?
Yes
No
Please Describe
What Was The Mother’s Age At The Time Of Delivery?
Child's Health
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How Many Weeks Gestation Was The Child Born?
What Was the Child's Weight and Size?
How Was The Child Delivered?
Vaginally
Cesarean Section
Please Describe Any Complications or Concerns During Labor or Delivery
Check All that Apply
Adenoidectomy
Asthma
Behavior Concerns
Brain Injury
Breathing Problems
Cardiac Issues
Chicken Pox
Diabetes
Ear Infections
Ear Tubes
Encephalitis
Frequent Colds
High Fever
Measles
Meningitis
Mumps
Seizures
Sensory Concerns
Sleep Issues
Tongue-Tie
Tonsillitis
Tonsillectomy
Traumatic Brain Injury
Vision Issues
Is The Child Up To Date With Immunizations?
Yes
No
Please Describe
Has The Child Ever Had Surgery?
Yes
No
Please Describe
Has The Child Ever Been Hospitalized?
Yes
No
Please Describe
Has The Child Ever Been In A Serious Accident?
Yes
No
Please Describe
Does The Child Have A Chronic Illness?
Yes
No
Please Describe
Is The Child Currently On Any Medications? If So, Please List Medication Name and Reason For Medication
Does The Child Have Any Known Allergies?
Yes
No
Please Describe
Does The Child Currently Use Any Equipment? (Communication Device, Walker, Etc.)
Yes
No
Please Describe
Does The Child Have A History of Ear Infections, Tubes, Etc. or Use Hearing Aides?
Yes
No
Please Describe
Does The Child Have Any Known Hearing Loss?
Yes
No
Please Describe
If You Have Any Concerns About The Child’s Hearing, Please Describe
Describe The Child’s Current Health Status
Is The Child Currently Receiving Any of The Following Services?
Developmental Pediatrician
Neurologist
PT
OT
SLP
Behavioral Therapist
Educational Consultant
Psychologist / Psychiatrist
Vision Therapist
Other
If Yes, Please List The Person’s Name And Last Date of Service
Developmental History
At What Age Did The Child Do The Following
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Sit Alone
Walk
Combined Words
Understood by Others
Crawl
Made Sounds
Sentences
Toilet Trained
Stood Up
First Word
Fed Self
Dressed Self
Does The Child Do Any of The Following
Choke On Liquids
Choke On Foods
Avoid Foods
Maintain A Special Diet
Use A Pacifier / Suck Thumb
Mouth Objects
Please Describe Any of The Above
If Under 4 Years Of Age, About How Many Words Does The Child Say
0-20
21-50
51-100
101-150
151-300
301-500
501+
Does The Child Produce Sentences of The Following Length
2 Words
3 Words
4 Words
5 Words
What Percentage of The Child's Speech Do You Understand?
How Well Do People Outside of The Family Understand Their Speech?
If The Child Is Not Using Words, How Do They Communicate?
Does The Child Have Any Difficulty With The Following
Attention
Aggression
Anger
Answering Simple Questions
Answering –Wh Questions
Chewing or Eating
Excessive Drooling
Following Directions
Frustration Tolerance
Maintaining Eye Contact
Understanding People
Producing Speech Sounds
Reading
Remembering
School Work
Stuttering
Transitions
Word Retrieval
Other Difficulties
Please Describe Any Of The Above
Has The Child Experienced Any Difficulty With Feeding or Swallowing? If So, Please Describe
Educational History
Is The Child Currently Enrolled In Daycare/ School
Yes
No
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What Is The Name of The Program?
What is Their Grade Level?
What Day(s) Do They Attend?
Type of Classroom
If They Receive Any Accommodations, Please Describe
Please Describe Any Educational Difficulties or Learning Challenges That This Child Has Faced
Social History
Describe How The Child Interacts With Parents, Siblings, or Other Family Members
Please Describe The Communication Difficulties The Child Faces In The Home Environment
Describe Any Significant Events or Changes Within The Home
What Are The Child’s Strengths?
What Are The Child’s Weaknesses?
What Are The Child’s Favorite Activities?
Does The Child Participate In Any Community Activities (Ex. Play Groups, Sports, Etc.) And How Is Their Communication / Behavior?
Does The Child Become Easily Frustrated With Certain Activities? If So, Please Explain
Describe How The Child Interacts With Other Children
What Are Your Goals for The Child Over The Next 6 Months?
What Are Your Goals for The Child Over The Next 5 Years?
Is There Anything Else That Is Important for Us To Know About The Child?
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Name Participant or Legal Representative
*
Relationship To The Child
*
Signature of Participant or Legal Representative
Clear Signature
Submit
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