*Child's Name:

*Birthdate:

*Age:

Gender: Male Female

*Parent or Guardian Name:

*Phone:

City of residence:

*Email:

*Programs or services interested in: Speech Therapy Occupational Therapy Preschool programs Tutoring Social Skills

*Please describe your main concerns:

*Please check specific areas of concern: Attention Behavior Speech-Language Sensory Social skills Motor skills Learning and academics Following directions Feeding issues Transition and flexibility Understanding and comprehension Tantrums Sleep patterns Focus Articulation

Does your child currently have services? (If your child is currently receiving services please describe what kind of services and how many times per week they are receiving them.)

Diagnosis: (OPTIONAL) Has your child previously been diagnosed with any other particular condition that would affect his or her speech, language, auditory or motor skills? (such as Down Syndrome, PDD, Cerebral Palsy, Hearing Impairment, etc.) If so, what is their diagnosis?

Describe child's health from ages 1-3:

Date of last medical checkup:

Is your child currently in good health?

Was your child's early development: Early Average Late

At what age did your child sit alone?

Age your child first crawled?

Age your child said their first words?

Age your child used 2-3 word phrases?

Age your child walked without holding?

Age your child used sentences?

Has your child had a hearing test? Yes No

Results of recent hearing test:

Does he/she follow verbal directions?

Does he/she turn head toward sound?

Primary method(s) of communicating? Gestures Sign Langauge Cooing Babbling Grunting Word Approximations Single Words Short Phrases Sentences

Is your child talking? Yes No

Does your child use a lot of gestures? Yes No

Is he/she frustrated with talking? Yes No

Do they seem disinterested in talking? Yes No Sometimes

Do they answer simple yes/no questions? Yes No

Is your child's speech intelligible? Yes No Somewhat

Does he/she avoid or overreact to touch? Yes No Sometimes

Areas where your child has difficulty:

Regulating their behavior? Yes No Sometimes

Manipulating small objects? Yes No Sometimes

Self help skills: Yes No Sometimes

Catching or throwing a ball? Yes No Sometimes

Please check behaviors that apply: Aggression Unusual fears Depression Impulsive Non-compliant Low self-esteem Tics or nervous gestures Manipulative Nail-biting Nightmares Hyperactivity Lack of motivation/apathy Short attention span Sleep problems Frequent crying Truancy Moodiness Perfectionist

Additional comments: