Contact Form Year Round

    DEVELOPMENTAL QUESTIONNAIRE

    Please Fill Out Completely

    Today's Date:

    Child's Name:

    How old is your child?

    Date of Birth:

    MaleFemale

    What are you concerned about?

    Parents

    Parents are:MarriedNever MarriedSeparatedDivorcedDeceased

    Age:

    Does family have a history of speech and language difficulties?

    YesNo

    If yes, please explain:

    Siblings

    Male or Female?

    MaleFemale

    Do siblings have a history of speech and language difficulties?

    YesNo

    If yes, please explain:

    At Present

    *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

    Medication

    To Treat What?

    Frequency

    Side 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

    Have any feeding/swallowing difficulties?

    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?

    YesNo

    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**

    ****Effective 11/30/2020, the immunization protocol is suspended. When we begin to meet again in person, the immunization protocol will be back in effect.****

    **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.