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GROUP Intake Form: Speech with Wit
Please complete this form to get on the group speech/therapy list.
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Email
*
Your email
Parent/Guardian's name(s):
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Your answer
Mailing Address:
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Your answer
Phone Number:
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Your answer
Language spoken in the home:
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Your answer
Child's name (first and last):
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Your answer
Child's Date of Birth:
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MM
/
DD
/
YYYY
What are the areas of concern?
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Articulation / Speech Sound Production (How the child pronounces sounds and words)
Receptive or Expressive Language (How the child understands and uses words to communicate)
Fluency (Stuttering, difficulty getting words out)
Augmentative and Alternative Communication (AAC)
Social Skills / Pragmatics (How the child uses language socially)
Other:
Required
Please provide EXAMPLES of errors / areas of concern.
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Your answer
Describe any relevant medical history (including hearing screenings/test, PE tubes, medical diagnoses, complicated pregnancy, etc)
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Your answer
What are your main goals/hopes to get from services?
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Your answer
In order to best match skills and needs, please check all that describe your child.
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Primarily uses gestures and movement to communicate.
Communicates using 1-2 word phrases/sentences.
Communicates using 3-4 word phrases/sentences.
Communicates using 5+ word phrases/sentences.
Has difficulty following directions.
Can often follow simple, 1-step directions.
Can often follow 2-3 step directions.
Can follow complex directions.
Required
Does the child receive any other speech-language therapy supports or services?
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Yes (If yes, please provide more information at the end of the form)
No
Other:
Does the child receive any other support services such as ELL, special education, Title I reading, tutoring, etc?
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Yes (If yes, please provide more information at the end of the form)
No
Other:
Are you also interested in individual speech/language therapy services with Speech with Wit?
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Yes
No
Maybe - tell me more
Please share any additional information you think would be relevant to this child.
*
Your answer
Send me a copy of my responses.
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