New Client Packet

Please complete the following forms prior to your evaluation or first session at The Kids' Communication Center.

Page 3

CLIENT INFORMATION

Re-enter child's full name:

What languages are spoken in the home or in any of your child’s other settings?

Does your child communicate with gestures?

Sounds (e.g., grunts)?

At what age did your child begin using one-word utterances?

Two-word utterances?

Give examples of several phrases your child often uses (e.g., “want milk”)

Do others understand your child when he/she communicates?

Do you understand your child when he/she communicates?

Is your child showing signs of frustration arising from his/her communication?

At what age did your child begin to crawl?

To walk?

Describe your child's crawl.

Does your child interact well with peers?

With adults?

Does your child make eye contact with others?

List other professionals working with (or who have worked with) your child:

Name & Profession

Phone Number

Has your child been treated by another speech-language pathologist? (Please provide name, telephone number, and reason).

Does your child attend school, day-care, or other program? (specify name, days attended, and length of day)

Describe the child’s current activity level (low, typical, high).

What is your child's current sleep pattern? (e.g., sleeps from _____ to _____ and naps from _____ to _____)

What activities does your child enjoy the most?

What activities does your child refuse to do?

How does your child spend most of his/her time?

How much time does your child spend watching television per day?

Does your child have difficulty calming him/herself?

Does your child respond to his/her caregiver with a facial expression, gesture, or vocalization? Y/N

Does your child show back-and-forth communication (e.g., gesture, facial expression, or verbalization) with his/her caregiver? For example, mom smiles at child, child coos, then mom coos and child reaches to be picked up, then mom smiles and then baby laughs). Y/N

Clicking Submit will take you to page 4.