Individual Therapy Intake Form

CONSENT TO USE VIDEO OR PICTURED IMAGE & AUDIO RECORDING

**This form must be signed in order for you/your child to participate in the program**

The use of video, picture image and audio recordings are an essential component to our social groups. We must be allowed to use these types of recordings in order for you or your child to participate in our program.
Please check the first two boxes to indicate that you will allow these recordings and wish to participate in our program:

I give permission for Speech & Language Specialties to use the image of my child within the clinic setting for therapeutic purposes.
I give my permission to audio tape my child for clinical purposes.

POLICIES AND PROCEDURES

Financial Responsibility:
I hereby agree to accept full responsibility for all fees for services rendered to the patient by the practitioner. Payment is due at the completion of each session and/or evaluation.

Cancellation Policy:

Speech and Language Specialties Inc. is dedicated to providing services to our clients. We must stress that consistency of attendance is crucial in order for clients to effectively meet the goals of their treatment plan. In addition, therapy time is specifically reserved for your family and is unavailable for other clients.

We are sensitive to the needs faced by the families of our clients however; it is necessary for us to enforce a cancellation policy. Except in cases of emergency or sudden illness, appointments not cancelled 24 hours in advance will result in a charge as though the appointment was held.

We look forward to a positive relationship to you, as we strive to provide quality treatment. Thank you for your attention to this matter.

I agree to cancellation policy

Family Involvement:

Parents and caregivers are encouraged to attend the last 10 minutes of each therapy session to explore with the therapist the new ideas learned during the session. Each client’s growth and progress depends on continued exposure and carryover in outside environments by the adults and professionals supporting them. It is central for these team members to learn new concepts, vocabulary, and strategies along with the child/client.

Applications:

Please fill out prior to initial intake. Remember, the more time slots you make available for us to choose from, the more likely it will be that we are able to place your child in our clinic.

Fee Schedule for Individual Therapy Services

Please fill out prior to initial intake. Remember, the more time slots you make available for us to choose from, the more likely it will be that we are able to place your child in our clinic.

CONTACT FORM

Date:

Client name

Birth Date

Insurance Provider

Insurance #

Mother's Name:

Occupation:

Address:

City:

ZIP:

Home Phone:

Cell Phone:

Work #:

Email:

Father's Name:

Occupation:

Address:

City:

ZIP:

Home Phone:

Cell Phone:

Work #:

Email:

SIBLINGS

Name and Age:

Name and Age:

Name and Age:

Name and Age:

School Name and District/City:

PLEASE LIST ANY FOOD ALLERGIES OR DIET RESTRICTIONS FOR YOUR CHILD:

Needs Epi-pen:
yesno

PLEASE PROVIDE EMERGENCY CONTACT INFORMATION:

Emergency Contact Name:

Contact Phone:

Relationship to client:

PARENT ASSESSMENT

Child’s Name/Nickname:

Current Educational Setting:

Public SchoolPrivate SchoolHome SchooledCombination

Current Services:

OTSpeechSpecialized Classroom1:1 AideOther

Diagnostic Label:(for insurance purposes)

Autism Spectrum Disorder (ASD)Non-verbal Learning Disorder (NLD)Attention Deficit-Hyper Activity (ADHD)Attention Deficit Disorder (ADD)Expressive/receptive language delayNo diagnosisAnxietyOther
What language(s) does the child speak? What is the primary language?:

With whom does the child spend most of his/her time?:

Describe the child’s speech and language skills, how does the child communicate (gestures, single words, short phrases, sentences)?:

When was it first noticed? By whom?

Has the problem changed since it was first noticed?

Is the child aware of the problem?

Does the child use speech meaningfully?
NoYes
Can the child’s parents understand speech?
NoYes
Can playmates, teachers, and relatives understand speech?
NoYes
Were there any feeding problems? (sucking, swallowing, drooling, chewing)
NoYes
If yes, explain:
Is there any history of ear infections?
NoYes
If yes, explain:
Has any other speech-language specialists seen the child? Who and When? What were their conclusions/suggestions?

Are there any other speech, language or hearing problems in your family? If yes, describe.

Prenatal/Birth History

Describe mother’s general health during pregnancy

Were there any unusual conditions that may have affected the pregnancy or birth?

Medical History

Were there any unusual conditions that may have affected the pregnancy or birth?
Describe and provide approximate age at which the child suffered the following illnesses and conditions.
AllergiesAsthmaChicken PoxTinnitusColdsConvulsionsCroupTonsilitisDizzinessDraining EarEar InfectionsHeadachesHigh FeverMastoiditisMeaslesMeningitisMumpsPneumoniaSeizuresSinusitisOther:
Any Hospitalizations? If yes, explain

Any Surguries? If yes, explain

Is the child taking any medication? If yes, identify.

Developmental History

Provide approximate age at which the child began to do the following activities:

Use single words (ex. No, mom, doggie etc.)
YesNo
Combine words (ex. me go, daddy shoe etc.)
YesNo
Name simple objects (ex. dog, car, tree etc.)
YesNo
Use simple questions (ex. where’s doggie? etc.)
YesNo
Engage in conversation
YesNo
Does the child have difficulty walking, running or participating in activities, which require small or large muscle coordination?
Describe the child’s response to sound?

What are your current concerns about your child’s performance at school?

Receptive Language Development (Processing): Check all that apply
Processes information quicklyUses new concepts readily, incorporates new vocabulary into communicationLearns new concepts with repetition, needs cues to use new vocabulary. Visual and physicalcues helpfulDelay in response timeUnderstands communication when paired with visual and physical prompts.Very concrete comprehensionChild has difficulty understanding the concepts and language introduced – requires visual and/orphysical prompts to understand message.

Expressive Language Development: Check all that apply
Advanced vocabulary and sentence structure.Age expected vocabulary and sentence structure.Slightly delayed vocabulary and sentence structure.Significantly delayed vocabulary and sentence structure.

BEHAVIORS: PLEASE CHECK BEHAVIORS THAT DESCRIBE YOUR CHILD. PLEASE CHECK ALL THAT APPLY.

MotivatedAnxiousExternally distractedImpulsive OppositionalAloof/ internally distractedRigid(my way or the highway attitude)Physically aggressiveVerbally aggressive to peers or adultsWithdrawn (may hide or emotionally shut down when upset)

THERAPY: Individual Speech and Language Therapy / Dates: Monday-Friday

Additional Questions

What does your child like to do?

What does your child dislike?

Therapy goals and additional comments or concerns:

Thank you for taking the time to complete this form. It is greatly appreciated and will be helpful in completing your child’s intake process here at SLS. We look forward to working with you and your child!

Δ