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Let's Talk! Intake Form
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* Indicates required question
Client Name:
*
Your answer
Date of Birth:
*
Your answer
Parents/Legal Guardians:
*
Your answer
Address:
*
Your answer
Phone:
*
Your answer
Email:
*
Your answer
Preferred Method of Contact
*
Email
Text
Phone
Required
Does your child currently see a Speech-Language Pathologist?
*
Yes
No
Other:
What are your child's current communication or literacy goals?
*
Your answer
What are your family's priorities at this time?
*
Your answer
Does your child attend any of the following?
School
After-school program
Daycare/preschool program
Extracurricular activities
Other:
How would you describe your child?
*
Your answer
What are your child's biggest interests?
*
Your answer
What are your child's biggest strengths?
*
Your answer
What areas does your child find challenging?
*
Your answer
What motivates your child?
*
Your answer
Has your child been diagnosed with any of the following?
Autism Spectrum Disorder
Learning Disability
Hyperactivity or Impulsivity
Developmental Delay
Depression or Anxiety
Vision Impairment
Hearing Impairment
Other:
What treatment is your child currently receiving?
Speech-Language Pathology
Occupational Therapy
Tutoring
Other:
Details of current treatment plan (Service Provider, where, how often,etc)
Your answer
Where would you like sessions to occur?
*
Online
Home
After school program
Daycare/Preschool
Extracurricular activity
School
Other:
Required
How often would you like sessions to occur?
*
Weekly 1 hour sessions (4 hours/ month)
Weekly 2 hour sessions (8 hours/month)
1 hour Biweekly sessions (2 hours/month)
2 hour biweekly sessions (4 hours/month)
PECS Intensive Training (3, 3 hour sessions in one week)
Other:
Are you interested in...?
Supporting your child in using their skills in the community?
Getting practice in peer interactions
Other:
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