Authorization Form

Authorization Form

I hereby give permission for a speech and language evaluation to be performed at the Santa Rosa RiteCare® Childhood Language Center. I understand the purpose of this evaluation is to determine the nature and extend of my child’s speech/literacy and/or language difficulties. This evaluation will be performed by a certified, licensed speech-language pathologist. All reports regarding this evaluation will be confidential and remain in the Center files unless otherwise requested by me.

I hereby give permission for speech-language therapy to be provided to my child at the Santa Rosa RiteCare® Childhood Language Center. This therapy shall be provided by a certified, licensed speech-language pathologist or a graduate student clinician who is under the supervision of a certified licensed speech-language pathologist.

Signature:_____________________________________________


Date:

Relationship to Client:

Client’s Name:


DEVELOPMENTAL QUESTIONNAIRE

Please Fill Out Completely

MaleFemale

What are you concerned about?

Parents

Parents are:MarriedNever MarriedSeparatedDivorcedDeceased

Does family have a history of speech and language difficulties? YesNo

If yes, please explain:

Siblings

MaleFemale

Do siblings have a history of speech and language difficulties? YesNo

If yes, please explain:

At Present

YesNo

*All children must be up to date on all required immunizations prior to enrollment.

Does your child:

Wear glasses?YesNo

Have allergies?YesNo

If yes, please list:

Currently sees a physician for conditions other than regular check-up? Explain:

Takes Medications? YesNo

MedicationTo Treat What?FrequencySide Effects

Seems to be emotionally and mentally healthy?YesNo

If no, explain:

Sees an orthodontist?YesNo

For what reason?

Have any feeding/swallowing difficulties?YesNo

Explain:

Birth

Is the child adopted?YesNo

Length of Pregnancy:

Was the delivery normal?YesNo

If no, explain:

Was the mother’s health good during the pregnancy?YesNo

If no, explain:

During pregnancy, did the mother:

Smoke?YesNo

Drink Alcohol?YesNo

Use Drugs?YesNo

Child’s weight/condition at birth:

Development

Does your child have a history of ear infections?YesNo

If yes: Frequency

At what age did your child reach these developmental milestones?

Sat up alone

Dressed Self

Crawled

Walked Alone

Toilet Trained

Motor coordination is:ExcellentGoodPoor

Behavior/Discipline

Does your child have playmates in the neighborhood?ExcellentGoodPoor

Seems to be a leader or a follower?LeaderFollower

Prefer to play with people or things? PeopleThings

What seems to motivate your child?

What pleases you most about your child’s behavior?

What bothers you most about your child’s behavior?

Method of discipline used?

How often does your child need to be disciplined?

Discipline has been:StrictLenientInconsistentAdequate

Age of first words: Age of first sentences:

When did your child’s speech/language first concern you?

How has the family attempted to improve the child’s communication?

What do you think may have caused the problem?

Has your child been seen or evaluated by:

Speech-Language Pathologist?YesNo

Name: Agency: Date:

Developmental Psychologist?YesNo

Name: Agency: Date:

Developmental Pediatrician?YesNo

Name: Agency: Date:

Occupational Therapist?YesNo

Name: Agency: Date:

**PLEASE ATTACH ANY OTHER SPEECH AND LANGUAGE AND/OR MEDICAL REPORTS THAT MAY BE PERTINENT TO YOUR CHILD’S THERAPY HERE AT THE CENTER**

**PLEASE ATTACH DOCUMENTATION OF ALL VACCINATIONS IN THE FORM OF YOUR CHILD’S IMMUNIZATION RECORD OR A SIGNED STATEMENT FROM A MEDICAL DOCTOR**

IN ORDER FOR YOUR APPLICATION TO BE COMPLETE, YOU MUST PROVIDE ALL PREVIOUS TEST SCORES, SUCH AS ACHIEVEMENT'S TEST.