Form.… · Web viewWho does the child primarily reside with (list primary contact first)?

Lively Speech and Language TherapySarah Lively, M.Ed., CCC-SLPSmlively.SLP@gmail.com(904) 395-7132

Group Instruction Form

Client InformationChilds Name _______________________________ DOB _______________Street Address ____________________________ School ____________________________City, Zip: ______________, ______________ Grade (in Fall 2017) ______________

Parent/Guardian InformationWho does the child primarily reside with (list primary contact first)?Name ____________________________________ Name _____________________________________Relationship ____________________________ Relationship _____________________________Occupation ______________________________ Occupation _______________________________Best method of contact? Best method of contact?Phone/Text _____________________________ Phone/Text ______________________________Email ____________________________________ Email _____________________________________

Who else has custody of this child?_________________________________________________________________________________________________

Please list the names/ages of any siblings (please include “half” and “step” siblings.)_________________________ _________________________ ________________________

Emergency Contact: ________________________________________ Phone: ____________________________

Pediatrician’s Name:________________________________________ Phone _____________________________

Client HistoryPlease describe any complications/injuries during pregnancy or birth:

Please list any recent hospitalizations/medications:

Please circle any existing diagnoses given by a medical professional (doctor, psychiatrist, psychologist, speech-language pathologist, audiologist, occupational therapist, physical therapist, etc.)

Autism Emotional Disorder Recurrent Ear Infections SeizuresADHD or ADD Genetic Syndrome Recurrent Fevers Cleft LipAllergies Hearing Impairment Vision Problems Cleft PalateDyslexia Cognitive Impairment Learning Disability Other:

Please circle “YES” or “NO” for the following:

Does your child have a 504 for Testing Accommodations at school? YES NO

Does your child have an Individualized Education Plan (IEP) at school?If yes, what is your child’s exceptionality(s)?

YES NO

Does your child have a Functional Behavioral Plan (FBP-BIP) at school?If yes, what behavioral strategies work?

YES NO

Did your child pass his/her last hearing screening? YES NO

Does your child have a history of chronic ear infections? YES NO

Has your child ever had PE Tubes in his/her ears?If yes, date of last PE Tube placement:

YES NO

Does your child receive private tutoring outside of school?If yes, for what subject(s) and where?

YES NO

Does your child receive any speech or language services outside of school?If yes, which services and where?

YES NO

Has your child’s teacher reported that he/she is below grade level expectations?If yes, which subject(s) and when?

YES NO

Please circle the skills your child can currently perform proficiently.

Understands spoken language Blends sounds to make a word Understands when read to

Understands spoken “wh” questions Decodes consonants in text Understands what he/she reads

Rhymes Decodes short vowels Generates main idea

Counts syllables Decodes consonant blends Generates key details

Names all letters Decodes long vowels Speaks clearly about what is read

Names sounds all letters make Reads fluently with intonation Writes clearly about what is read

Concerns/Comments: