Child Intake Form Age 0-5 - Erika Phillips

Name of person completing form *

Relationship to the client *

Child's name *

Gender

Date of Birth *

Age *

Primary Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Parent / Guardian Name(s) *

Phone *

Phone

Email *

Email

Other children at home (name & age) *

If none please add "N/A"

Referred by (e.g. parent/school/doctor)

How did you find me?

What are your speech and language concerns? *

Has the child been seen by a speech-language pathologist? *

Yes
No

If yes, please describe (when, name of SLP and facility and findings)

Medical History

Does your child have any diagnoses or disorders? *

Yes
No

If yes, please describe

Do you have concerns that your child may have symptoms of a specific condition?

Yes
No

If yes, please describe

Has the child been seen by other professionals (e.g. Psychologist, Pediatrician, Ear Nose & Throat Specialist, Occupational Therapist, Reading Support, Physiotherapist etc.) *

Yes
No

If yes, please describe

Has your child had any major illnesses or injuries? *

Yes
No

If yes, please describe

Does your child have any allergies? *

Yes
No

If yes, please describe

Does your child drool? *

Yes
No

Speech and Language History

What is your child's first language? *

Do they speak any other languages?

When did your child say their first words? *

When did your child combine words to form sentences? *

Is your child able to communicate what they want to say? *

Yes
No

How does your child typically communicate (eg. with gestures or words)? *

Give an example of something your child communicated today (either with words or gestures) *

If with words, how many words does your child typically put together to form a sentence?

Does your child understand *

Single directions (e.g. point to your nose)?
2 step directions (e.g. get your shoes and give them to me)?
Simple questions (e.g. where’s your teddy?)

How well do you understand your child (from 0% to 100%)? *

Numbers Only

How well do other family members understand your child (from 0% to 100%)? *

Numbers Only

How well do strangers understand your child (from 0% to 100%)? *

Numbers Only

Are there certain sounds that your child has difficulty pronouncing? *

Yes
No

If yes, provide examples

Is your child aware of their difficulties? *

Yes
No

What does your child do if they are not understood?

Does your child stutter? (e.g. gets stuck, repeats sounds/words) *

Yes
No

If yes, describe (e.g. how long they have been stuttering, family history of stuttering, how it impacts your child)

Hearing

Has your child had ear infections? *

Yes
No

If yes, how many & when?

Did your child have tubes? *

Yes
No

If yes, when?

Does the child seem to have any difficulty hearing? *

Yes
No

If yes, describe

Has your child had a hearing test? *

Yes
No

If yes, describe the results and recommendations

Vision

Has your child had a vision test? *

Yes
No

If yes, date tested & results

Social History

Does your child enjoy or avoid the company of other children? *

What are your child’s interests? What do they like to do? *

What is your child good at? *

Birth History

Were there any problems during the pregnancy/delivery? *

Yes
No

Please describe any complications during pregnancy or birth

Was your child born early (premature)? *

Yes
No

If yes, how many weeks gestation?

Education

Does your child currently attend school? *

Yes
No

If yes, list school and grade

Has your child’s teacher reported any concerns? *

Yes
No
Not applicable

Is your child currently receiving any supports at school?

Additional Comments

Please share any other information that you feel is important.

Terms and Conditions

I grant informed consent for Erika Phillips Speech Language Pathology’s Therapists to provide assessment, treatment and consultation to the client listed on this form *

I understand and consent to Speech Language services.

No show or late cancellation

No shows will be billed at the full hourly rate. Cancellations within 24 hours will be billed at the full hourly rate. The fee may be waived if a make-up session is scheduled outside of the regular treatment frequency. *

I understand that I may be billed for no shows and late cancellations.

Investment

The rate charged by Erika Phillips Speech Language Pathology for the services listed below will begin at $170 per hour. All therapy sessions may be subject to indirect fees which can include 15 minutes of billable time. Indirect fees include consultation, treatment preparation, treatment documentation, coordination, etc. Services that will be invoiced according to Erika Phillips Speech Language Pathology rates: Initial consultation to meet client, Screening, Assessment, Intervention, Consultation with family, school or team members, Therapy preparation, Documenting sessions, Participation in team meetings, Goal plan writing and updating, Writing reports and treatment summaries, Training aides, Completing forms, Preparing a home program, Telephone consultation of 15 minutes or more in length *

I understand the details of my investment and I understand that all of the services listed are billable

Family participation

The client may be asked to complete activities and/or carry out strategies and recommendations outside of the treatment sessions. Assistance from family members/parents/guardians/friends will support the client's progress and they are welcome to attend the sessions. *

I understand that family participation is encouraged

Teletherapy & Digital security and confidentiality

I understand that teletherapy includes the use of interactive audio, video or and data communication. I understand the risks associated with teletherapy which can include technical difficulties, transmission of information may be disrupted or distorted, information could be interrupted or accessed by unauthorized persons. I understand the benefits associated with teletherapy can include but are not limited to the following: the client has access to therapy from anywhere in Alberta, may increase regularity and consistency, and can help the client achieve goals and outcomes. I understand that email transmissions, completed forms and all of the therapist's documentation are stored online through a platform that complies with the Protected Health Information privacy rules. I understand that safeguards have been established to protect privacy and confidentiality but no technological communication system is entirely secure. *

I understand the risks associated with digital communication and storage and consent to teletherapy services (if applicable)

Full Name *

By writing your name you agree all statements are true and agree to a binding contract.