Copy of Forms | little tides speech therapy

Welcome to

Little Tides Speech Therapy!

Before your complimentary 15-minute consultation, please complete the form below.

This information will help Erin prepare for your call so your time together can be as helpful and meaningful as possible.

We look forward to connecting

with you soon!

Parent/Guardian First name

Parent/Guardian Last name

Child's First and Last Name

Child's Pronouns

Child's Birthday

Month

Day

Year

Email

Phone

Address

Are there other children in the family? Please specify age and if they have hearing or speech problems.

Do you feel your child has difficulties with speech and/or language? If yes, please describe.

Do you feel your child has a hearing problem? If yes, please describe.

Has your child ever had a speech-language evaluation/screening? If yes, where and when?

Has your child ever had a hearing evaluation/screening? If so where and when?

Has your child ever had speech therapy? If so, where and when?

Has your child received any other evaluation or therapy (physical therapy, counseling, occupational therapy, vision, etc.)? If so, please describe

Is your child aware of, or frustrated by, any speech/language difficulties?

What do you see as your child’s most difficult problem in the home?

Does your child...(check all that apply)

choke on food or liquids?

currently put toys/objects in his/her mouth?

brush his/her teeth and/or allow brushing?

repeat sounds, words or phrases over and over?

understand what you are saying?

retrieve/point to common objects upon request (ball, cup, shoe)?

follow simple directions (“Shut the door” or “Get your shoes”)?

respond correctly to yes/no questions?

Does your child currently communicate using... (check all that apply)

If your child is in daycare/preschool/school, If so, please provide details

What do you see as your child’s most difficult problem in daycare/preschool/ school?