Pediatric Speech And Language Intake Form (Page 5 of 5) in pdf

Pediatric Speech And Language Intake Form Page 5

Does your child have regular responsibilities? Please describe.

_______________________________________________________________________

Educational History:

Does your child currently attend school? Please indicate school name, grade,

and schedule.

_______________________________________________________________________

How is your child performing in school? Does your child enjoy school?

_______________________________________________________________________

Has your child’s teacher expressed any concerns?

_______________________________________________________________________

Does your child receive any special services at school? Does your child

currently have an Individualized Educational Plan (IEP)?

_______________________________________________________________________

Does your child receive any therapy services (speech therapy, feeding therapy,

occupational therapy, physical therapy)?

_______________________________________________________________________

*What is your purpose for initiating this evaluation?

_______________________________________________________________________

Thank you for taking the time to complete this form

Courtney T. Gessin, MS, CCC-SLP, Speech-Language Pathologist

Pediatric Speech And Language Intake Form Page 5