Speech & Language Development Information (Child)
This form will provide information about your child's speech and language development. Content given in this form will allow TeleVine Therapy to have a better understanding about your child.
Email address *
Child's Name *
Your answer
Child's DOB *
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DD
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YYYY
Parent/Legal Representative Name *
Your answer
Do you remember your child lying in their crib and making play type sounds, such as cooing and/or babbling? *
Do you remember this child attempting to copy or mimic words, gestures, games (Peek-a-boo, patty-cake)? *
Does anyone in the family have a hearing or speech problem? If so, what relation are they to your child? *
Your answer
At what age was your child when he/she said his/her first meaningful word? What was it? *
Your answer
At what age was your child when he/she used 2 word phrases? Please provide an example. *
Your answer
At what age was your child when he/she used sentences? Please provide an example. *
Your answer
Are there some words that this child appears to understand but cannot say, such as bye-bye, baby, no, cookie, bath, etc.? List examples below. *
Your answer
Check any and all statements which accurately describe this child’s present speech and language behaviors. *
Required
Does your child use a spoon/fork? *
If your child uses a spoon/fork, what hand do they use?
Describe your child's eating habits and neatness. *
Your answer
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