Get Diagnostic Intake Form For Preschool And School-age

Completing the Diagnostic Intake Form for Preschool and School-Age Children is an essential step in understanding and addressing speech and language needs. This guide provides clear instructions for filling out the form accurately and comprehensively online.

Follow the steps to complete the form successfully

1. Click the ‘Get Form’ button to access the form and open it in your preferred online editor.
2. Begin by entering your child's name, date of birth, and age in the designated fields. Ensure that all information is accurate to help with the assessment.
3. Provide your home address and phone number. This will allow the center to contact you if necessary.
4. Indicate your child's gender by checking the appropriate box and fill in the city, state, and zip code.
5. In the 'Referred by' section, include the name of the person or organization that recommended your child for assessment.
6. Fill out the parent or guardian information. Include the names, occupations, and day phone numbers of both parents or guardians, as well as any relevant addresses.
7. List other household members, including their names, ages, and relationships with your child.
8. In the 'History of Speech/Language Problems' section, describe your child's speaking difficulties, when they were first noticed, and any changes over time.
9. Answer the questions regarding any previous assessments or therapies your child has had, including results and treatment focus.
10. Complete the 'Medical History and Current Health Status' section honestly, providing information about your child's development, ear infections, and any medical concerns.
11. In the 'Speech Fluency and Stuttering' section, detail your child's stuttering history, awareness, and the impact on their academic and social life.
12. Describe how often your child speaks fluently in various situations and rate their ability to speak freely.
13. Summarize any additional information about your child's hobbies, interests, and overall social skills in the final section.
14. If you wish to subscribe to the Stuttering Center’s e-Newsletter, provide your email address.
15. Once you have filled in all sections, review your responses for accuracy. Save your changes, and download, print, or share the completed form as necessary.

Complete the Diagnostic Intake Form online to ensure your child's speech and language needs are addressed promptly.