Client Information

Child’s Full Name: _____________________________________ Today’s Date:

_________________

Phone number: ___________________________ Date of Birth:

______________________________

Address: _______________________________ City: ______________________ State:

__________

Legal Guardian(s):

____________________________________________________________________

Who does the child reside with? (Please include names and ages of siblings)

________________________

__________________________________________________________________________________

Child’s primary language: _____________________ Other languages spoken:

_____________________

Will the person accompanying the child require an interpreter? __________________________________

Medical History

List any current medications:

___________________________________________________________

List any recurrent illnesses:

____________________________________________________________

List prior hospitalizations:

_____________________________________________________________

List previous surgeries:

_______________________________________________________________

Did your child pass newborn hearing screen?

_______________________________________________

When was your child’s last well-child checks?

_______________________________________________

Name of pediatrician/medical practice:

____________________________________________________

Did the child require any medical interventions at birth? If so, please describe.

______________________

__________________________________________________________________________________

_

Did the child come home from the hospital with the parent after delivery? If not,

please describe. _______

__________________________________________________________________________________

_

List other consulting medical professionals:

________________________________________________

Developmental History

Please indicate if there is a family history of any of the following:

Learning difficulties

___________________________________________________________________

Developmental delays

_________________________________________________________________

Speech/Language Disorder

_____________________________________________________________

Mental Health Concerns

_______________________________________________________________

Hearing/vision impairments

____________________________________________________________

At what age did your child first do the following:

Sit: ______________ Crawl: ______________ Walk: ______________ Smile:

______________

Laugh: _____________ Babble: _____________ Wave hello/goodbye: _____________

Say first word: ___________ Put two words together: ____________ Follow

directions: ____________

At what age did you first become concerned about your child’s development? ______________________

Social

Does your child seek out friends? Rarely Seldom Sometimes Often Always Does your child relate to other children? Rarely Seldom Sometimes Often AlwaysDo other children seem to relate to your child? Rarely Seldom Sometimes Often AlwaysDoes your child seem to understand how to play with others? Rarely Seldom

Sometimes Often Always

Does your child make attempts to get others to interact with him/her? How?

______________________

__________________________________________________________________________________

_

What are your child’s favorite play/recreational activities?

______________________________________

__________________________________________________________________________________

_

Does anyone have concerns about any of your child’s behaviors?

________________________________

__________________________________________________________________________________

_

Do your child’s communication skills keep him/her from interacting with others

or making friends? _____

__________________________________________________________________________________

_

Communication & Language

How much of what your child says do you understand? How much would a

stranger understand? _______

__________________________________________________________________________________

_

Do you feel like your child is aware of his/her communication difficulties?

________________________

Is your child easily frustrated while trying to communicate with others?

___________________________

Does your child talk about things that are interesting to them?

__________________________________

Does your child ask questions to get more information?

_______________________________________

Does your child ask what new words mean?

________________________________________________

Do you notice your child learning and using new words on a regular basis?

________________________

Can your child tell you a simple story that makes sense?

_______________________________________

Does your child use location words (such as up, down, under, behind, etc)

appropriately? ________________

Does your child use action words (such as run, read, eat, laugh, etc) appropriately?

____________________

Does your child use past tense (such as walked, smelled, looked) appropriately?

_______________________

Does your child use plurals (such as shoes, apples, books) appropriately?

_____________________________

Does your child use pronouns (me, you, he, she) appropriately?

_________________________________

Educational/Academic

Does your child attend school?

__________________________________________________________

Has the teacher expressed concerns about your child’s classroom behaviors?

Please explain ____________

__________________________________________________________________________________

_

Has the teacher expressed concerns about your child’s classroom performance?

Please explain _________

__________________________________________________________________________________

_

Do you have concerns about how your child is doing (or will do) in school?

________________________

Please indicate if your child is performing above, below, or at grade level in the

following subjects:

Reading _________ Spelling _________ Writing _________ Math _________

Science _________

Does your child have a IFSP/504/IEP? (If yes, please provide a copy)

____________________________

Does your child receive any other supports at school?

________________________________________

Previous Therapy

Has your child received any therapy or intervention in the past? (OT, PT, SLP,

Vision, Hearing, Mental Health) Please list:

____________________________________________________________________

Is your child currently receiving any therapy?

_______________________________________________

If so, what goals are being addressed?

_____________________________________________________ What goals or skills would

you like to see your child work on in therapy now? ______________________

What do you hope to gain/learn from this evaluation?

________________________________________

__________________________________________________________________________________

_