New Client Packet

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

Page 4

CLIENT INFORMATION

Re-enter child's full name:

Which of the following concern you? (check all that apply)

number of words your child uses in a sentence

your child’s pronunciation of words

your child’s ability to understand language

your child’s play/social skills

your child’s eating habits

your child’s ability to maintain attention

your child’s ability to read

your child’s ability to use language to converse (back-and-forth dialogue)

Please explain.

Does your child repeat a word or sound within an utterance (e.g., “like like like this one mom”)?

How many times does your child repeat the repeated sound or word? (Two or less? Three or more?)

How many times a day does your child repeat a word or sound within an utterance?

Is your child repeating sounds, syllables, or words? (Provide examples)

How long has your child been repeating sounds, syllables, or words? (Provide approximate dates)

Is your child left-handed or right-handed?

What do you hope therapy will accomplish?

Who will implement a speech and language home program?

Who recommended that you see a speech-language pathologist?

How did you hear about The Kids’ Communication Center?

Have other family members been treated by a speech-language pathologist?

If so, why?

Have any immediate family members been diagnosed with autism?

Do you plan on filing for insurance reimbursement?

Have any extended family members been diagnosed with autism?

Name of insurance?

Name of insured:

Policy no.:

Clicking Submit will take you to page 5.