Preschool Speech Delay Intake Form

Child Information

Child's Name Date of Birth Gender Male Female Other

Parent/Guardian Information

Parent/Guardian Name Relationship to Child Phone Number Email

Developmental History

Pregnancy and Birth History Developmental Milestones (e.g., sitting, crawling, walking)

Speech & Language Concerns

Primary Speech/Language Concern Age when first words were spoken Age when phrases/sentences began Other languages spoken at home

Medical History

Has your child had a hearing test? If so, when and results? Any current/past medical conditions, diagnoses, or medications?

Additional Information

Other services your child receives (e.g., OT, PT, ECI, etc.) Any family history of speech/language delays? Other relevant information