CHILD FIND INTAKE
Utilized to gather information from parents requesting evaluations.
* Required
Email address
*
Your email
Child's Name
*
Your answer
Gender
Female
Male
Clear selection
Date of Birth
*
MM
/
DD
/
YYYY
Place of Birth
*
Your answer
Home Address
*
Your answer
Parent/Guardian's Name
*
Your answer
Phone #
*
Your answer
Parent/Guardian's Name
Your answer
Phone #
Your answer
Who does the child primarily live with?
*
Mother
Father
Both parents
Stepmother
Stepfather
Grandparents
Other:
Required
Siblings & Ages
Your answer
Language(s) spoken in the home
*
English
Spanish
Other:
Required
Language(s) child understands
*
English
Spanish
Other:
Required
Language(s) child speaks
*
English
Spanish
Other:
Required
Does the parent or child need an Interpreter?
*
Yes
No
Does the child participate in a childcare program, Mother's Day Out program or preschool program?
Yes
No
Other:
Clear selection
Does the child currently receive any type of therapy or services (speech therapy, OT, PT, etc.)?
Your answer
Is your child currently under the care of a physician?
*
Yes
No
Other:
Are there any concerns with your child's vision?
*
Yes
No
Other:
Are there any concerns with your child's hearing?
*
Yes
No
Other:
What concerns do you currently have about your child?
*
Your answer
Speech/Language
*
My child only has a few words in vocabulary; doesn't put words together to communicate.
My child doesn't seem to understand; has difficulty following directions.
My child is hard to understand; speech is unclear.
My child stutters or unable to speak with fluency.
No concerns
Other:
Required
Social
*
Consistently shows limited/no interest in playing or engaging with others
Rarely makes eye contact (looks at) others
Becomes upset in group settings
Gets stuck on one idea/object/activity and becomes upset if asked to change
Appears to be in his/her own world
Appears shy with others
Appears fearful with others
No concerns
Other:
Required
Social - If one or more items were marked above, please describe what the behavior looks like, how often does it occur and how severe is it.
Your answer
Emotional/Behavioral
*
Refuses to comply with requests
Easily frustrated
Unable to accept limits
Throws tantrums
Aggressive with others
No concerns
Other:
Required
Emotional/Behavioral - If one or more items were marked above, please describe what the behavior looks like, how often does it occur and how severe is it.
Your answer
Attention
*
Darts from one task to another
Difficulties with changes in routine
Short attention span
Easily distracted
No concerns
Other:
Required
Developmental/Cognitive
*
Delays in meeting developmental milestones
Difficulties learning new skills (behind peers)
Difficulties repeating information just heard (for example - if you say, 1, 2, 3 can they repeat it back.)
Difficulties imitating or copying a pattern up to four objects (for example - a line of cars, blocks or familiar objects)
No concerns
Other:
Required
Self-Help
*
Significant delay in feeding
Significant delay in dressing
Significant delay in toilet training
No concerns
Other:
Required
Any additional information you would like to share about your child.
Your answer
A copy of your responses will be emailed to the address you provided.
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