Speech Therapy Client Intake Form Pediatric Case History Child's First Name* Child's Last Name* Child's Date of Birth* Parents First Name* Parents Last Name* Address* City* State* Zip* Phone* Email* How did you hear about us?* Insurance Carrier* Insurance ID* Insurance Group* Pediatrician's name Speech Concerns:* Languages sopken and/or exposed to* Development Milestones At what age did your child begin to: Crawl* Walk* Say first functional words* Combine 2 words together* Medical History Questions Describe your pregnancy* NormalComplications Delivery* NormalComplications Medical Diagnoses* YesNo Do you have concerns with your child’s hearing?* YesNo Has your child had any ear infections?* YesNo Has your child had any prior hospitalizations/surgeries?* YesNo Is your child takig any medication?* YesNo Is there a family history of a speech delay, speech disorder, disability, etc?* YesNo Does your child attend an educational program? Grade Name of school/preschool: Additional support in school DDoes your child currently receive any therapy services? PT OT Speech ABA Other
