Welcome to Windy Road

SPEECH THERAPY BRIEF ADMISSIONS FORM

Welcome

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Child Information and Services

Services Requested
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Gender

Evaluation Concerns and Therapy History

Is any language other than English spoken in the home?
Current therapy services your child is receiving
Does your child have an Individualized Education Program (IEP) or Individualized Family Service Plan (IFSP)?
Has your child had a psychological or neuropsychological evaluation completed?

Medications, Allergies and Medical History

Hearing and Vision

Hearing Test

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Vision Test

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Specialists and Relevant Medical History

Speech Development

Indicate the approximate age at which your child reached the following milestones:

Did anything concern you about your child’s speech development?
Does your child prefer to communicate with:
Does your child follow simple directions?
Does your child understand what you are saying?
Does your child identify objects and actions easily?
Does your child respond correctly to yes/no questions?
Is your child’s speech easily understood by most people?
Is your child aware of or frustrated by any speech/language difficulties?

Interests and Activities

Parent Signature

Thank you for this information related to your concerns as they relate to speech/language therapy. This allows your evaluating therapist to select the most appropriate assessment tool(s) for your child.