SpeechAbility Intake Form, Johnson County, KS

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Dyslexia: Should My Child Be Evaluated?

intake form FOR DYSLEXIA CONCERNS

Child's Name *

First

Last

Primary Language *

Date of Birth *

Sex *

Male Female

Secondary Language *

Child's Pediatrician/Primary Care Physician *

Family members living with child *

Mother's Name *

Mother's Email *

Home Address (number, street, city, state, zip) *

Work Phone *

Home Phone *

Cell Phone *

Employer *

Occupation *

How do you prefer to be contacted? *

Father's Name *

Father's Email *

Home Address *

Work Phone *

Employer *

Home Phone *

Cell Phone *

Occupation *

How do you prefer to be contacted? *

Has any family member ever received speech or language therapy or had a history of speech or language difficulties? *

Yes No

If yes, please list relation to child and type of difficulty. *

Has child had hearing tested or screened? *

Yes No

Date *

Place of Testing *

Results of hearing testing or screening *

Has child had vision testing or screened? *

Yes No

Date *

Place of testing *

Results of Vision Test *

Please list child's medications, surgeries, allergies and any other relevant medical information (including birth history) *

Please list all medical diagnoses you child has been diagnosed with. *

What are your child's personal interests and likes? *

What are your child's strengths? *

What are your child's dislikes? *

ACADEMIC CONCERNS

Does your child: *

Attend home-school Attend public school Attend private school

Please list what grade your child is currently in. *

Please list school name, school district, and city of your child's school. *

What is your primary concern regarding your child's reading difficulties? *

Does your child ever confuse their left from their right? *

Yes No

What did the school do when you expressed concern about your child's struggles? *

Has your child ever had an IEP or 504 Accommodations? *

Yes No

If yes, when did he/she receive this? *

When did you first notice your child's academic struggles? *

Has your child ever received outside tutoring or therapy? *

Yes No

If yes, please list program names(s)/therapy attended. *

Have any biological family members or relatives been diagnosed with dyslexia? Have any struggled with reading or spelling? *

Yes No

If yes, what is the relationship to your child? *

What do you hope to achieve from this evaluation? *

How did you hear about SpeechAbility? *

Submit

Allison Winters
M.Ed., CCC-SLP
Shawnee, KS 66216
913-777-4SLP (4757)
SpeechAbilityLLC@gmail.com
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What a Client Says

"Our son, Sam, has Down syndrome and has worked with Allison as his SLP. Since Sam was born, one of the primary terms we hear is "advocate", with the focus being on our need to be Sam's advocate. We are pleased to point to someone else who stepped in to be Sam's advocate, Ms. Winters. She had already impressed us several times while she was working with Sam. One particular improvement that we saw, and that has continued, is that Sam is working hard to finish the last syllable in words." --Rachel O.