SpeechAbility Intake Form, Johnson County, KS

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intake form FOR DYSLEXIA CONCERNS

All information provided will remain confidential. Please fill out to the best of your ability. This information is needed in order to make official diagnosis.

* Indicates required field

Child's First Name *

Child's Middle Initial/Name *

Child's Last Name *

Sex: Select One *

Date of Birth *

Primary Language *

Child's Pediatrician/Primary Care Physician *

Physician Phone *

Physician Address *

Are Shots Current? *

Date of Last Flu Shot *

Mother's contact informaton

Mother's First Name *

Mother's Last Name *

Mother's Email *

Mother's Address *

City, St, Zip *

Phone Number *

Cell Phone *

Occupation *

Employer *

How Do You Prefer to Be Contacted? *

father's contact information

Father's First Name *

Father's Last Name *

Father's Email *

Father's Address *

City, St, Zip *

Work Phone *

Employer *

Cell Phone *

Occupation *

How Do You Prefer to be Contacted? *

Has any family member ever had difficulty with reading or spelling, including slow reading? Have they received speech or language therapy or had a history of speech or language difficulties? *

Yes No

If yes, please list relation to child and the specific 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 include whether all developmental milestones were met (talking, walking, playing). If not, please list the specific delay and how it was addressed. THE MORE SPECIFIC INFORMATION GIVEN THE MORE IT WILL HELP the EVALUATOR. *

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

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

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

Grade your child is currently in. *

School District *

City and state school is located *

School Name *

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 ? *

Yes No

Date Initiated *

Is IEP still current? *

Has your child ever had a 504? *

Yes No

Date Initiated? *

Is 504 still current? *

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

Have any biological family members or relatives been diagnosed with dyslexia? Have any struggled with reading or spelling? This includes slow reading or spelling even if it has never been diagnosed. *

Yes No

Has your child ever received outside help with reading? *

Has your child ever received speech therapy, physical therapy, or OT? Please include dates *

Please list family relation to your child. *

How did you hear about SpeechAbility? *

What do you hope to achieve from this evaluation? *

Thank you for taking time to fill out this Intake form. These answers WIll help your child receive the appropriate diagnosis.

Submit

Allison Winters
M.Ed., CCC-SLP. C-SLT
Shawnee, KS 66216
913-777-4SLP (4757)
SpeechAbilityLLC@gmail.com
Site Built by Compelling Communications

What Clients Say

“Allison has been a critical part in helping my daughter learn how to read more efficiently and she is now reading above her 5th grade-level. I am so thankful for all she has done for our family.” -Amy

“Not only were we able to schedule an evaluation with Mrs. Winters within 3 weeks of initially calling, she answered all of my questions so we knew exactly what to expect on the day of testing. She also set aside time for a separate 2 hour meeting for my husband and me explaining all of Nathan’s results and gave us a plan to help him with his reading!” -Nicki N.

"Mrs. Winters helped me a lot with my reading. At first I didn't like having to go see her every week after school but now I don't mind at all because I can read!" -Luke Z.