Center for childhood communication department of speech-language pathology

Download 40.11 Kb.
Size40.11 Kb.

Thank you for your interest in speech-language pathology services at The Children’s Hospital of Philadelphia.
Outpatient speech and language evaluation and therapy services are provided at several locations:

  • Pennsylvania: Main Campus in Philadelphia (Buerger Center for Advanced Pediatric Care, 5th Floor), Brandywine Valley (Glen Mills), King of Prussia, Exton, Bucks County (Chalfont)

  • New Jersey: Voorhees, Mays Landing (Atlantic County), and Princeton at Plainsboro

Please read this entire letter as it contains important information regarding your child’s appointment.
Prior to requesting an appointment, please complete the enclosed Speech and Language Evaluation Questionnaire. This allows us to accurately schedule the evaluation and provides the speech-language pathologist with your child’s medical, developmental, and educational history. Additionally, please forward copies of other records pertinent to a speech and language evaluation (e.g., hearing test results, reports from psychologists, neurologists, and developmental pediatricians, previous speech-language evaluations, and educational reports such as IEPs, IFSPs, etc.). Please fax the completed questionnaire and other relevant records to 267-426-5934, or mail it to:
Speech Intake Coordinators

The Children’s Hospital at The Wanamaker Building

100 Penn Square East

6th Floor – Access Center

Philadelphia, PA 19107
Always keep a copy of these documents for your own records. Once we receive the evaluation questionnaire and any related documents, a scheduler will call you to set up an appointment.
Information about your child’s evaluation
During the evaluation, our speech-language pathologist will perform an assessment of your child’s ability to understand language, expressively communicate, and use his/her voice to speak clearly and fluently.
At the end of the evaluation, we will give you information about your child’s speech and language abilities, appropriate medical, educational and community resources to meet your child’s further assessment and therapeutic needs, home programming ideas, and recommendations and goals for therapy.
If hospital-based therapy services are recommended as a result of the evaluation, please be aware that we follow a “medical therapy model.” As a result, we are primarily a diagnostic center with a focus on evaluation services and a commitment to helping families understand treatment options for their children. Short-term therapy is available, when appropriate, with the goal of transitioning services to educational and community settings that will be able to meet your child’s long-term therapeutic needs if necessary.
Appointment guidelines

  • Please arrive 15 minutes prior to your scheduled appointment to complete the registration process

  • Allow up to 90 minutes for the completion of the evaluation

  • Your child must be accompanied to the evaluation by a parent or legal guardian

  • In an effort to obtain the best attention from your child and assessment of his/her skills, it is preferable that siblings do not accompany your child to the appointment

  • Please make sure you understand and comply with your insurance benefits, coverage limitations and requirements, including co-payment, referral, prescription coverage, etc.

Any questions you may have will be answered by the speech-language pathologist at the time of the evaluation or thereafter. We look forward to meeting you and your child.


For office use only:

MR# ­­­­­­­­­­



Please complete and return this questionnaire, using black ink. The information will be used to assist in the proper scheduling and evaluation of the child. All information will be kept confidential.
Person filling out this questionnaire Relationship to child

Who referred you to this facility?

Please √ appointment type needed: Initial/New Evaluation (never seen by CHOP speech)

Re-evaluation (seen by CHOP speech before)
preferred location(s) for evaluation: Next available/Any site

NJ Voorhees Mays Landing Princeton at Plainsboro

PA CHOP (Phila) Chalfont Exton King of Prussia Brandywine Valley

Has the child had a hearing test within the past year (circle)? YES / NO
Language(s) spoken at home

Interpreter needed: For parent(s)? Yes / No What language?

For child? Yes / No What language?

Child’s name Birth date

Address Age

Parent Parent

Address Address

Home phone Home phone

Marital status Marital status

Age ______________________________ Age

Education ______________________________ Education

Occupation ______________________________ Occupation

Employer ______________________________ Employer

Work phone ______________________________ Work phone

Cell phone ______________________________ Cell phone

Email ______________________________ Email ________________________

Name of child’s physician/practice Phone

Primary Insurance Secondary Insurance

Names, ages and relationships of those living in the child’s home:

Name Age Relationship to child

_______________________ _________

_______________________ _________

_______________________ _________

­­­­­_______________________ _________

Child’s Name: Date of Birth:


What are the primary concerns you have about the child’s speech, language or voice?

In which of the following areas does the child seem to have difficulty? Check all that apply.

_________ Hearing sounds _________ Voice difficulties

_________ Understanding what others say

_________ Saying speech sounds

_________ Learning and using new words

_________ Using sentences

_________ Stuttering

_________ Feeding

_________ Other (Please describe)

Who first noticed the problem(s)? When?

Apart from speech, language and hearing, are there concerns about the child’s development in other areas (e.g., coordination, play skills, making friends, cooperativeness, self-help skills such as toileting and dressing, general activity level)? Please describe.

Was child adopted? If so, from where and at what age?

Were labor and delivery normal? ­­ Type of delivery?

Was the child premature? Length of pregnancy? Birth weight

Were any of the following used by the child’s mother during pregnancy?

Cigarettes Alcoholic drinks

Prescribed drug

Nonprescribed drug

Did the mother experience any illnesses, accidents or injuries during the pregnancy? Please describe.

__________________________________________________________ Which trimester

__________________________________________________________ Which trimester __________________________________________________________ Which trimester
Please describe any medical problems the child had during the first few weeks of life (e.g., jaundice, seizures, breathing difficulties, feeding difficulties, etc.).

Did the child pass the newborn hearing screening? Yes No

How long did the child stay in the hospital following birth?

Child’s Name: Date of Birth:

Has the child had any of the following conditions? If so, please note how old the child was when the condition occurred and if it is a continuing problem.

Condition Age(s) Condition Age(s)

Allergies __________ Head injury __________

Asthma __________ Heart disease __________

Chronic colds __________ High fever __________

Cytomegalovirus (CMV) __________ High Lead Level __________

Ear infection __________ Meningitis __________

Encephalitis __________ Seizure __________

Other: please list

Has the child ever been hospitalized for treatment of an illness or accident? Please describe and give dates.

Has the child ever had surgery (please describe and give dates)?
Has the child been examined by the following specialists? List dates and results and attach reports.

Specialist Date Findings/Agency

____ Allergist _________

____ Audiologist (hearing) _________

____ Cardiologist (heart) _________

____ Developmental Pediatrician _________

____ Geneticist _________

____ ENT (ear/nose/throat) _________

____ Neurologist _________

____ Ophthalmologist (vision) _________

____ Orthopedist _________

____ Psychiatrist _________

____ Psychologist _________

____ Other _________
Please list any medication(s) the child takes regularly.

Medication Reason




Does the child currently have or use: ______ Other adaptive equipment (e.g., wheelchair)

______ Eyeglasses ______ Bottles

______ Hearing aid(s) ______ Pacifier

______ Dental braces ______ Sippy cup

______ Oral appliance ______ Spoon

______ Assistive communication device ______ Thumb sucking/finger sucking

Is the child considered a picky eater? If so, please list the child’s food preferences:

Child’s Name: Date of Birth:

Please list any of the child’s relatives having the conditions listed below (e.g., hearing loss/grandfather).

Mental retardation/Intellectual Disability Autism/PDD

Developmental Delay Speech/language problem

Cleft palate Reading problem

Other birth defect Learning disability

Hearing loss Other:

At approximately what age did the child: Walk alone Become toilet trained

Begin to babble? (e.g., bababa, dadada, gagaga, etc.) Did it seem normal?

First produce a true word (e.g., “ball”, “car”, “truck”)? What was the word?

Begin to say two or more words in a sentence, such as “baby down”; “more juice”?

Does the child follow simple spoken directions?

How many words do you think the child uses (says)? (You can estimate)

Does the child speak: Often Sometimes ______ Rarely Never

Does the child become frustrated when not understood: Often _______ Sometimes ______

Rarely ______ Never _______

What percent of the time does the family understand the child’s speech?

What percent of the time do strangers understand the child’s speech?

Has the child ever spoken better than he or she does now? Please explain.
Does the child’s speech ever seem to get better or worse? Please explain.
Has the child ever had a speech and language evaluation? If so, where?

When? Results?

Has the child ever had speech and language therapy? If so, where?

When? How often? Still Receiving?


Name of school or day care

Days and times child attends school or day care

School District Grade in School

Previous school attended ______________________________ Date ________________ Ages

Previous school attended ______________________________ Date ________________ Ages

If the child attends school or daycare, does the family or teachers have concerns about the child’s performance? If so, please describe them here.

Child’s Name: Date of Birth:

Has the child ever received testing? _________ When?

What type(s) of testing were completed?

Where was testing completed?

Please describe the results of testing: (Please attach copies of any available testing reports, IEP, etc.)
Has the child ever repeated a grade? ___________ If yes, which grade?

What was the reason for repeating?

Check all special services that the child has received or is currently receiving:

Please send a copy of relevant reports with this questionnaire to the Intake Coordinators or bring to the evaluation.

Early Intervention  What services?

Intermediate Unit  What services?

Special Class (e.g., Learning Support, Life Skills, Autistic Support)  Type?

Tutoring  Where? In what subjects?

Resource Room  For what subjects?

Occupational Therapy  Goals

Physical Therapy  Goals

Vision Therapy  Goals

Hearing Therapy  Goals

Other Services  Goals


What play activities does your child enjoy?

Have any significant changes occurred in the child’s family during the last few years (e.g., deaths, serious illnesses, separations, divorces, moves, etc.)? Please describe.
Is there any other information that might be helpful to us in understanding and assessing the child?

If so, please describe.

Your signature ______________________________________ Date

Download 40.11 Kb.

Share with your friends:

The database is protected by copyright © 2020
send message

    Main page