Form

Home Address *

Phone Number *

- Area Code Phone Number
Child's Birth Date *

Month Day Year
Gender *
Parent E-mail
Marital Status
Spouse's Name
Spouse's Email
Spouse's Number
Number of Children
Children's Names, Ages
Emergency Contact *
Emergency Contact Phone Number *
Primary Care Physician
Primary Care Physician's Phone Number
How were you referred to our office? *
Child's race/ethnic group *
Any other language(s) besides English spoken in the home? If yes, which one(s): *
What language does the child prefer to speak?
Does your child understand the language?

Financial Information
How I plan to pay for therapy: *

I plan to use my insurance. I want to pay for my therapy. Committee on Preschool Special Education Committee on Special Education Please explain my options
It is important that you call your insurance carrier to find out any information you may not know. If your insurance does not pay for services rendered, you are financially responsible
Primary Insured's Name *
Primary Insured's Date of Birth *
Primary Insured's Social Security Number *
Insurance Company *
Insurance Contact Number *
Member ID *
Specialist Co-payment *
Individual Deductible amount *
Deductible met? *
Referral needed for speech? Y/N *
Insurance Card
Please upload the front of your insurance card here:
Please upload the back of your insurance card here:
Number of authorized sessions *
Authorization Number *
You are aware that if your insurance company does not pay, you are financially responsible for any services rendered. Please type your name in the box to the right indicating that you are aware that you will be responsible should your insurance plan not pay. We will charge your insurance as a courtesy, but ultimately, you are responsible. *

Speech-Language-Hearing
Do you feel your child has a speech and/or language problem?
If yes, Please explain:
Has your child had a speech and or language evaluation in the past? *

Yes No
If so, when?
Where was the evaluation performed?
Please upload a copy of the most recent evaluation report:
What were the results of the evaluation? What were you told?
Has your child ever had speech therapy?
If yes, when and where?:
Is your child aware of or frustrated by any speech/language difficulties? If yes, explain:
What do you see as your child's most difficult problem in the home?
How does your child communicate? Check all that apply:

Body language Sounds (vowels, grunting) Words (shoe,doggy,up) 2 to 4 word sentences Sentences longer than 4 words Other
Did your child ever have a hearing screening/evaluation? *
If yes, when and where?
Please upload a copy of the latest report:
Has your child received any other evaluation or therapy (physical therapy, counseling, occupational therapy, vision therapy, etc.)? *

School History-If you child is in school, please answer the following:
Name of School and grade:
What are your child's strengths and/or best subjects
Teacher's name:
Is your child having difficulty with any subjects? If so, please explain:
Does your child have any interest in books? Describe:
Describe your child's current literacy/writing status. Does he/she recognize letters, sounds they make,trace, read?

Family History
Does anyone in your family have a history of speech/language delays or learning disabilities? If so, please explain:

Signature and Submission
Please type your name below to indicate consent to treatment.
Parent/Guardian Signature
Date

Month Day Year
Enter the message as it's shown *
If you have any additional concerns or questions not addressed:
If you have any additional concerns or questions not addressed:
If you have any additional reports that may help with the evaluation process, please upload them here:
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Speech and Language Case History Information