The EasySpeak Clinic

“The Orchids” Strathclyde Crescent, St. Michael

Tel: 235-4361 Email: easyspeakassist@gmail.com

SPEECH AND LANGUAGE THERAPY CLIENT INTAKE FORM

OFFICE CANCELLATION POLICY

Payment is due at the time services are rendered, unless prior arrangements have been made with the provider. Twenty-four hour notice is required for appointment cancellation or a fee of $50 will be assessed. After three non-verified cancellations, the provider reserves the right to terminate therapy services. The provider also reserves the right to terminate therapy services at any time for ANY reason deemed necessary.

Has your child been seen previously by a speech and language therapist?

Yes

No

Was your child born to term?

Were there any problems with pregnancy, birth or in the first few months?

Did your child have problems feeding at any time?

Did they crawl? – Age

What age did they walk?

Did your child babble a lot as a baby or was he a quiet baby?

How old was he/she when he put two or three words together to make a sentence?

Did your child point to what they wanted before they spoke?

Does/Did your child have any problems with listening or following directions?

Do you think your child understands everything you say to him/her?

Do you have difficulty understanding what he/she is saying?

Does you child have any behavior problems? Are you concerned about any behavior?

Is your child toilet trained?

If your child is at school, how are they progressing with academic work? Is their reading and spelling progressing at an appropriate age?

Does your child make eye contact when they are spoken to and/or speaking to you?

. Do any members of your family have speech/language/ learning difficulties?

Is your child in good health?

Allergies?

Has your child had his/her vision tested and what were the results?

Has your child had his/her hearing tested and what were the results?

Describe how you find your child’s speech and language, or their difficulties in general?

Thank you for taking the time to fill in this form!