Child's Name

Date of Birth

Gender

Parent/Guardian Name

Phone

Email

Address

Primary Language Spoken at Home Other Languages Spoken School/Preschool Name Current Grade/Year Level

Please describe the concerns about literacy or language

Any issues during pregnancy or birth? Age when major milestones were reached (sat, walked, first words, sentences)

Any known hearing or vision difficulties? Any previous diagnoses (e.g., ADHD, autism, etc.)? Current Medications

Any concerns raised by educators? Previous/current support received (e.g., tutoring, speech therapy, etc.)

Any family history of literacy, language, or learning difficulties?

Child’s strengths and interests Anything else you would like us to know?

Literacy and Language Disorder Intake Form