Child Intake Form
Today's Date
Client Name
Nickname
Date of Birth
Age
Gender
Female
Male
Diagnosis (if known)
Client's Physician Name
Physician Phone
Parent/Guardian Information
Parent(s) / Guardians Names
Email
Phone Number
Street Address
City
State
AL
AK
AS
AZ
AR
CA
CO
CT
DE
DC
FL
GA
GU
HI
ID
IL
IN
IA
KS
KY
LA
ME
MH
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
MP
OH
OK
OR
PW
PA
PR
RI
SC
SD
TN
TX
UT
VT
VI
VA
WA
WV
WI
WY
Zip
Martial Status
Single
Married
Divorced
Separated
Windowed
What adults does the child live with?
Birth Parent(s)
Grandparent(s)
Father only
Mother only
Adoptive Parent(s)
Foster Parent(s)
Both Parents
Emergency Contact Information
Emergency Contact
Relationship
Contact Information
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?
Was there any stress during the pregnancy?
Were there any complications during labor or delivery?
What was the mother’s age at the time of delivery?
How many weeks gestation was the child born?
Is the child up to date with immunizations?
Has the child ever been in a serious accident?
Does the child have a chronic illness?
Is the child currently on any medications?
Does the child have any known allergies?
Does the child currently use any equipment? (communication device, walker, etc.)
Does the child have a history of ear infections, tubes, etc. or use hearing aides?
Does the child have any known hearing loss?
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
Developmental History
At what age did the child do the following
Sit Alone
Stood up
Made Sounds
Combined Words
Crawl
Walk
Walk
First Word
Sentences
Fed Self
Understood by Others
Toilet Trained
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
If under 4 years of age, how many words does the child say
0-20
21-50
51-100
101-150
151-300
300+
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?
Does the child have any difficulty with the following
Attention
Aggression
Answering simple questions
Understanding people
Sensory Processing
Producing speech sounds
Reading
Remembering
Transitions
Education History
Is the child currently enrolled in daycare/ school
Grade Level
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
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
Is there anything else that is important for us to know about the child?
Parent/Guardian Name
Signature
Clear
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