Intake Form

* Fields are Mandatory.
Other professionals currently visiting (e.g. speech therapist, occupational therapist etc) (Name and Tel)
Any prescribed medication (to be taken long term )
Family Information
Address (Residence)
Name and relationship of other family members staying with you:
Index child’s birth order (e.g. 2nd of 3 children)
Emergency contact (name and number)
Other people involved in looking after the child besides mother
Preference of days / time for therapy
What are the issues that bring you to us today?
What name does your child call you? Other family/household members?
What languages are spoken in your home?
What language do you use to comfort your child?
Does your child have any difficulties in eating or drinking?
When your child wants something, such as a toy or a food item, how does s/he convey this message to you? ( such as pull your hand, point, whine, or speak)
When your child does not like something, such as a toy, what does s/he do?
When your child does not like or want an action activity (such as peek-a-boo) what does s/he do?
What does your child do when s/he is near peers? (approaching, making a noise, greeting with gestures or words, looking at the peer, grabbing at objects, giving objects, running away)
When your child talks does s/he use mostly academic speech (numbers, colors, shapes, facts, memorized story sequences) or is s/he able to express descriptions and feelings about the present interaction.
What does your child like to do when on his/her own? (play with ,on I-pad/ phone, T.V, small fiddlies around the house)
What is his typical way of playing? What does he do with the toys?
Who does he prefer playing with? (alone, with parent/house help, others)