LLA Therapy - New Clients

Family Information

First Name of Child:

Last Name of Child:

Birthdate:

Person Completing Form:

Relationship:

Name Family Members Living at Home:

Who referred you to us?:

Birth / Medical /Developmental History

Please check all that apply:

There were problems during pregnancy or difficulties at birth
Child was born before the due date
Child has been hospitalized
Child has had his or her vision checked
Child has been diagnosed with mental, physical or emotional disabilities
Child has been diagnosed as having allergies

Birth / Medical / Developmental Comments:

Hearing Status

Do you have any concern regarding your child's hearing:

Has your child had any ear infections:

If so, how many:

Has your child's hearing been tested:

If so, when, and what were the results:

Previous Testing/Therapy

Have your child's speech/language skills been evaluated:

If so, when, and what were the results:

Has your child received speech/language therapy:

If so, when:

My Concerns

Please check any concerns you may have regarding your child’s communication skills and feel free to provide details below:

Child's ability to pay attention, listen, and follow directions
Child's ability to understand what he/she hears
Child's ability to remember information
Child's development of words to express his/her needs
Child's ability to efficiently put words together to express him/herself
Accuracy of your child's grammar
Clarity of your child's speech? (e.g., Is your child difficult to understand)
Fluency of your child's speech? (i.e., Does your child stutter)
Clarity of your child's voice (i.e., Does your child sound hoarse, nasal, stuffy, etc)
Child's social skills? (i.e., Does your child effectively get along with other children)

Concern Comments:

School

Does your child attend school:

School Name:

Grade Level:

Teacher:

Does your child receive speech therapy in school:

School Therapist:

Sessions per week:

Does your child receive tutoring at school or privately:

Details:

General comments, concerns, and questions

Thank You!

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