INTAKE FORM

Background Information of speech and language Difficulties

Primary Language Spoken in the Home:

Describe the speech and language problems you notice with your child(ex. not talking, using only a few words, saying words incorrectly)

Is your child aware of their speech and/or language difficulties? Yes NO

If yes, explain:

What else would you like to share with me about your child's development (i.e your goal for your child, and any other information you think would be helpful in supporting you and your child)?