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Child's First Name:
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Child's Last Name:
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Date of Birth:
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Age/Grade:
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
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Gender:
boy
girl
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School:
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Mother's Name:
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Father's Name:
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Street Address:
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City:
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Zip:
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Home Phone:
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Work Phone:
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Cell Phone:
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Email:
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Referrred By:
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Preferred Method of Contact:
Home Phone
Work Phone
Cell Phone
Email
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Describe your concerns regarding your child (please be specific).
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Pediatrician (name, address and phone #):
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Please list diagnosis (if any) and date given:
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Is your child currently receiving any services?
Yes
No
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If receiving service(s), please indicate if services are provided through the school district, privately, or both. Please list therapist(s) names, frequency of service, starting date, ending date, etc.
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Any complications before, during, or after birth? Please explain, if any.
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Medical History: (chronic colds, ear infections, allergies, etc). Please explain if any.
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Is your child taking any medications?
Yes
No
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If yes, please list.
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Please list your child's allergies, food sensitivities, or special diets, if any.
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At what age did your child sit without support?
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At what age did your child crawl?
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At what age did your child walk?
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At what age did your child speak first words?
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At what age did your child combine 2-3 words?
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At what age did your child speak in sentences?
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How does your child currently communicate (single words, 2-4 word sentences, etc.)?
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Does your child have difficulty with (check all that apply):
Limited vocabulary
Following simple directions
Understanding what you are saying
Responding to questions
Being understood by others (speech)
Reading comprehension
Written expression
Word retrieval
Pragmatics/Social Skills
Math word problems
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Other difficulties (please explain in detail):
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At what age, did you first become concerned about your child's speech, language, or communication development? Please explain.
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Any other concerns or comments?
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