Center for childhood communication department of speech-language pathology
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- Please read this entire letter as it contains important information regarding your child’s appointment . Prior to requesting an appointment
- Information about your child’s evaluation
- THE CHILDREN’S HOSPITAL OF PHILADELPHIA For office use only : MR SLP CENTER FOR CHILDHOOD COMMUNICATION
- Initial/New Evaluation
- Has the child had a hearing test within the past year (circle) YES / NO Language(s) spoken at home
- List dates and results and attach reports.
- Please attach copies of any available testing reports, IEP, etc
- Please send a copy of relevant reports with this questionnaire to the Intake Coordinators or bring to the evaluation
- Your signature ______________________________________ Date
| CENTER FOR CHILDHOOD COMMUNICATION
DEPARTMENT OF SPEECH-LANGUAGE PATHOLOGY 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
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. THE CHILDREN’S HOSPITAL OF PHILADELPHIA For office use only: MR# SLP CENTER FOR CHILDHOOD COMMUNICATION DEPARTMENT OF SPEECH-LANGUAGE PATHOLOGY SPEECH AND LANGUAGE EVALUATION QUESTIONNAIRE 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
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: PRIMARY CONCERNS 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. BIRTH HISTORY 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
Did the child pass the newborn hearing screening? Yes No How long did the child stay in the hospital following birth? M Child’s Name: Date of Birth: EDICAL HISTORY 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.
____ Allergist _________ ____ Audiologist (hearing) _________ ____ Cardiologist (heart) _________ ____ Developmental Pediatrician _________ ____ Geneticist _________ ____ ENT (ear/nose/throat) _________ ____ Neurologist _________ ____ Ophthalmologist (vision) _________ ____ Orthopedist _________ ____ Psychiatrist _________ ____ Psychologist _________ ____ Other _________
_______________________________ _______________________________ _______________________________ 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:
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? Goals/Results?
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.
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 5 Directory: data -> files files -> Guidelines for Working with Men Perpetrating Domestic Violence files -> Accelerated Reader through Renaissance Place The only way to become a better reader is to read! files -> Accelerated Reader through Renaissance Place files -> Course Description files -> Short Term Consultancy-Design Engineers (3) Terms of Reference Organizational Background files -> Background files -> September 22, 1999 Federal Aviation Administration files -> What’s at Issue files -> President’s budget says cut aip funding, implement user fees february 6, 2008 What’s at Issue files -> Monitoring of Russian tv channels Download 40.11 Kb. Share with your friends:
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