Person Completing Form
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First Name
Last Name
Child's Name
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First Name
Last Name
Date of Birth
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MM
DD
YYYY
Name of School / Preschool
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Child's Grade
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Infant
Toddler
Pre-K
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Primary Parent/Guardian Contact Name
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First Name
Last Name
Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Home Phone
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(###)
###
####
Cell Phone
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(###)
###
####
Email
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Secondary Parent/Guardian Contact Name
First Name
Last Name
Secondary Parent/Guardian Contact Phone
(###)
###
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# of Siblings
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Names & Ages of Siblings
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Primary Language
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Secondary Language
Referred By
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Reason for Referral
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How did you hear about Sound Beginnings?
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Child's Pediatrician
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First Name
Last Name
Pediatrician's Phone #
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(###)
###
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Pediatrician's Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Does your child see any other doctors or specialists?
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No
Yes
If yes, please list any doctor's or specialists
Has your child currently or in the past received speech/language, occupational, physical therapy, or educational services?
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No
Yes
If yes, please indicated dates, location, and type of service.
Has your child ever received a diagnosis from another professional?
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No
Yes
If yes, please list.
Does your child have a history of ear infections?
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No
Yes
Did your child ever have tubes placed in his or her ears?
No
Yes
If yes, please indicate where and when.
Has your child's hearing ever been tested?
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No
Yes
If yes, please indicate where, when, and the results:
Has your child had his/her vision tested?
No
Yes
If yes, please indicate where, when, and the results:
Does your child have allergies?
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No
Yes
If yes, please list:
Is your child currently taking any medications?
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No
Yes
If yes, please list.
Has your child ever suffered from a serious illness or injury?
No
Yes
If yes, please list.
Please list any other medical concerns
Birth Hospital
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State
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Length of pregnancy
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Type of delivery
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Birth weight
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Did the child's mother have any illnesses or complications during pregnancy or delivery?
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No
Yes
If yes please describe.
Did your child require any medical procedures before, during, or after birth?
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No
Yes
If yes, please describe.
Was your child adopted?
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No
Yes
If yes, please provide any relevant information regarding pregnancy, birth, and development:
Milestone: Approximate age child sat alone
Milestone: Approximate age child crawled
Milestone: Approximate age child babbled
Milestone: Approximate age child walked
Milestone: Approximate age child spoke first word(s)
Milestone: Approximate age child combined words
Milestone: Approximate age child spoke in sentences
Checkbox
Please check any of the following that apply to your child either in the past or currently:
Please comment on the above items checked:
Please list any food allergies
Are there any other developmental or educational concerns? If yes, please describe.
Is your child aware or frustrated by his/her communication difficulties?
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No
Yes
If yes, how does he/she express this?
Is there any family history of speech, language, or hearing problems?
No
Yes
If yes, please describe.
Please list your child's current activities & interests:
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What are you child's strengths?
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Is there any other pertinent information you would like to include?
What would you like to see your child achieve through speech therapy?
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