Intake forms – Axis Therapy Center

Pediatric Speech Services Intake Form

Child’s Basic Information

Full Name:

Date of Birth:

Age:

Gender:

Address:

City/State/Zip:

Guardian / Parent Information

Primary Guardian Name:

Relationship to Child:

Profession / Occupation:

Phone Number:

Email Address:

Secondary Guardian Name:

Relationship to Child:

Profession / Occupation:

Phone Number:

Email Address:

Main Concern

Describe the main reason for seeking speech services:

Describe your child (strengths and weaknesses):

List your child’s hobbies and interests:

Medical History

Hearing Test:

Passed Failed Not Tested

Vision Test:

Passed Failed Not Tested

Describe any hearing/vision concerns:

Medical Conditions / Diagnoses:

Medications:

Allergies:

Pregnancy & Delivery History

Pregnancy Complications:

Yes No

Premature Birth:

Yes No

Delivery Type:

Vaginal Cesarean

Gestacional age (weeks):

Developmental Milestones

Sat alone:

Crawled:

Walked:

First word:

First phrase/sentence:

Toilet trained:

Concerns about development:

Social Skills Information

How does your child interact with peers?

Enjoys playing with others?

Yes No

Preferred play type (parallel, cooperative, etc.):

Initiates play?

Difficulties:

Other:

Speech & Language Development

Age started using single words:

Age started combining words into sentences:

Speech clarity:

Concerns:

Primary language(s) at home:

Educational Information

Current School / Program:

Grade / Classroom Type:

IEP / 504 Plan:

Yes No

Insurance Information

Insurance Carrier:

Policy Number:

Group Number:

Policy Holder Name & DOB:

Please, upload your insurence card

Credit Card Information (Billing)

Name on Card:

Card Number:

CVV:

Billing Zip Code:

Services

Other:

Survey

Other:

Previous Therapies

Therapy Type:

Facility:

Dates:

Progress:

Primary Doctor / Pediatrician

Name:

Address:

NPI:

Phone:

Email:

FAX:

Signature & Consent

Parent/Guardian Signature:

Date: