SpeechAbility Intake Form, Johnson County, KS

intake form FOR literacy CONCERNS

All information provided will remain confidential. You will receive a Confirmation notice on this page once it has been submitted. please make sure all boxes have been entered. Thank you.

General patient Information

* Indicates required field

Child's First Name *

Child's Date of Birth *

Child's Middle Initial/Name *

Child's Last Name *

Child's Gender *

Male Female Prefer Not To Answer

Pediatrician *

Physician's Address *

What are your child's personal interests? *

What are your child's strengths? *

What are your child's dislikes? *

Parent 1 contact information

Parent First Name *

Parent Last Name *

Parent Email *

Parent Address *

City, St, Zip *

Employer *

Parent Cell Phone *

Parent Occupation *

How Do You Prefer to Be Contacted? *

Parent 2 contact information

Parent First Name *

Parent Last Name *

Parent Email *

Parent Address *

City, St, Zip *

Employer *

Parent Cell Phone *

Parent Occupation *

How Do You Prefer to be Contacted? *

Family History

Has any biological family member ever had difficulty with reading or spelling, including slow reading? *

Yes No

Has any biological family member been diagnosed with dyslexia? *

Yes No

If a biological family member been diagnosed with dyslexia, please state the relation to the child. *

Patient Medical history

Has your child had hearing tested or screened within the last year? *

Yes No

Date *

Place of Testing *

Results of hearing testing or screening *

Has your child had vision testing or screened within the last year? *

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. *

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

Is your child allergic to tree nuts? *

No Yes

Is your child allergic to dogs? *

No Yes

ACADEMIC CONCERNS

Does your child: *

Attend public school Attend private school Attend home-school school

Grade your child is currently in. *

School District *

City and state school is located *

School Name *

Has your child ever had an IEP? *

No Yes Not sure what an IEP is.

If yes, is the IEP still current ? *

Yes No

Date the IEP was Initiated *

Goals on the IEP include: *

Reading goals Speech-language goals Both reading and speech goals Goals unrelated to reading or language

Has your child ever had a 504 for reading? *

Yes No Not sure what a 504 is.

Date the 504 was Initiated? *

If yes, is the 504 still current? *

Yes No

What accommodations/modifications are included? *

Has your child ever received reading help outside of school using a structured literacy approach? *

How did you hear about SpeechAbility? *

What do you hope to achieve from this visit? *

Once you have submitted this form correctly, you will receive a confirmation page. Thank you.

Submit

Allison Winters
M.Ed., CCC-SLP. C-SLT
Shawnee, KS 66216
913-777-4757

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.

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