Client Intake Form (Child)

Client Intake Form (Adult)

Policies & Procedures

Release of Information

Video Consent Form

Client Intake Form (Parent on behalf of Child)

All of the information you provide will be kept confidential and will only be used for evaluative and therapeutic purposes.

You have two options for filling out the form:

1) Scroll down and fill in the form online and submit.

2) View, download, print, handwrite your responses and bring to your first meeting with Lucia Reardon.

Download Intake Form

Please note that Lucia Reardon Speech Language Pathology, LLC does not accept payment through insurance companies. Clients are provided with a monthly bill that may be submitted to their health insurance, if appropriate.

Clients must read, understand and agree to the terms and conditions in the Policies and Procedures of Lucia Reardon Speech Language Pathology, LLC. Clients will be provided with a printed copy and agree to be responsible for the payment for speech and language therapy treatment, evaluation and consultation services rendered as outlined to commence and receive services.

This form will be printed out at the time of the first consultation. The parent/guardian/client will sign and date it and the form will be retained in the client’s file.

Client Intake Form (Parent on behalf of Child)

* Required information

Client Intake Form (Parent on behalf of Child)

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Child's Full Name*
Date of Birth*
School Name
Age and grade in school
Parent(s)/Guardian(s) Names:(Required)
Parent(s)/Guardian(s) Names*
Parent(s)/Guardian(s) Names:
Parent(s)/Guardian(s) Names:
Home Address(Required)
Home Address*
Telephone Number*
Your Email Address(Required)
Your Email Address*
Physician's Name

Health History

Does your child have a specific diagnosis / diagnoses? Please list and give the age it was made.
Any difficulties at birth or right after birth?
Has your child had any history of high fevers, convulsions?
Has your child had any accidents or surgeries?
Has your child had any frequent or chronic ear infections?
Allergies (foods, etc.)
Does your chid regularly take medications? If so, please indicate type of medication and reason for taking.
Is your child on a special diet? Please specify:

Developmental History

Did your child develop speech and language milestones at the same rate and manner as typical peers?
Did or does your child struggle with processing sensory input?
If applicable, are there any problems understanding your child's communication? If yes, please explain.
Do other members of the family or teachers have difficulty understanding your child?
Does your child struggle with finding words?
Does your child experience any frustration with making himself/herself understood, or getting his/her ideas across?
Do you have any concerns about how your child understands language skills (i.e. following directions, answering questions)? if yes, please explain.

Executive Function History

What does your child find easy/enjoyable academically? What does your child struggle with academically?
Can your child prioritize, initiate and execute tasks associated with homework?
Is your child able to estimate how long it will take to complete a task similar to peers?
Can your child break large tasks or assignments into subtasks and timelines?
Does your child consistently leave tasks or assignments until the last minute?
Is your child able to adjust to changing circumstances or unexpected events in stride similar to same age peers?
Do small things affect your child emotionally and distract him or her from tasks at hand?
Is procrastination a problem for your child?

Social History

How is your child doing socially in school?
Is your child invited to parties, or social events by peers?
Does your child have friends?
Does your child show understanding of the feelings of others?
Does your child understand of the body language and facial cues of others?
Is your child aware of how he/she appears to others?
Is your child able to engage in socially appropriate and reciprocal behavior and conversation with her or her peers in a variety of settings/situations?
What are your child's social strengths?
What are your child's social weaknesses?
Describe some specific social difficulties experienced by your child.
What are your child's interests and is he/she able to disengage from this/these activity/ies if asked to or is required to engage in a less preferred activity?
Overall, how would you describe your child (e.g. happy, nervous, sense of humor, etc.)?

Family History

Names and ages of child's siblings
Do you have any pets at home? If so, name and type
Is there any history of speech/language or learning difficulties in your family? If yes, please explain.
What language(s) are spoken in your home?

Evaluation History

Has your child been seen for a speech/language, learning, psychological or neurological evaluation? If yes, please explain the reason for the evaluation and briefly summarize the findings of the evaluation.
Is your child under the care of another professional (i.e. psychologist/psychiatrist/counselor)? Please specify and give the reason why.
Has your child received communication, social-cognitive or executive function therapy in the past? If yes, please indicate the type of therapy and the approximate dates of therapy.
Has your child ever received a hearing evaluation? If yes, please indicate when the evaluation was done, who conducted the evaluation and the general results of the evaluation.

Summary

What are your goals for your child?
Please provide any additional information or insight here that you consider important.
Signature of Parent / Guardian (18 years or older)
Signature Date
MM slash DD slash YYYY
This field is for validation purposes and should be left unchanged.