Stellar Speech Therapy - Speech & Language Initial Questionnaire
Answers to the questions on this form will help us utilize our consultation time
Email address *
YOUR First & Last Name *
Phone Number *
What is your CHILD's first name? *
What is your CHILD's date of birth? *
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DD
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Is your child male or female?
Clear selection
What are your main concern(s) with your child's speech and language skills? Such as pronunciation (articulation); stuttering (fluency); lack of words or sentences (early language); vocabulary or grammar (language); autism; dyslexia; etc *
Has your child received a Speech and Language Evaluation or Speech Therapy in the past? *
If Yes...
Please summarize the evaluation results and/or previous therapy goals. Please include a summary of the diagnosis given.
Has your child been diagnosed with any potentially relevant medical conditions, such as autism, dyslexia, cerebral palsy, recurring ear infections, hearing impairment, etc? *
If Yes...
Please explain their diagnosis.
What language(s) are spoken in your home? *
What percentage of your child's spoken words do YOU understand? *
What percentage of your child's spoken words would a LESS FAMILIAR adult understand (e.g. A friend or family member who only sees your child occasionally)? *
Do you have concerns with how your child is understanding what you say (ex: following directions, answering questions, understanding stories being told, etc.)? *
If Yes...
Please describe your concerns.
Do you have any concerns with your child's hearing abilities? Consider how he/she reacts to sounds or words (i.e. doorbell, phone, calling his/her name). *
If Yes...
Please describe your concerns.
Has your child had a hearing screening? *
Does your child get frustrated when he/she is not understood? *
Does your child look at you (make eye contact) and react to your expressions (laugh, smile, etc.) as you would expect? *
If No...
Please describe how they react differently.
Did (or does) your child have any difficulty with feeding (i.e. gagging, difficulty swallowing, frequent coughing during meals)? *
What days and times work best for you and your child to attend a weekly 30-minute live therapy session using Zoom? *
Examples: Evenings and weekends | Saturday and Sunday mornings | Tuesday's between 2 to 4pm OR Friday afternoons
Do you have a computer or laptop with a webcam, or an iPad (or other large tablet) for live therapy calls over Zoom? *
Currently, I am an out-of-network provider. I am in the process of accepting some insurance plans. Please provide your insurance carrier for reference:
Use this box to provide any additional information about your concerns that is not covered in the questions above (optional).
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