Patient Information

Contact Information


Health and Medical History


Other Physicians and Specialists (i.e. pediatrician, neurologist, psychologist)

Past/Current Therapy Sessions



Speech/feeding milestone

Speech/feeding milestone

Motor milestone

Motor milestone

Speech and Feeding

Does your child:

Activities of Daily Living (ADL)

Please indicate the amount of assistance your child needs with the following tasks:

Goals for Therapy

Please list at least 3 goals per discipline that you hope to achieve with the help of therapy:

Additional Concerns

The information provided in the form helps our therapists tailor the evaluation to meets the needs of your child, so thorough responses are appreciated. Any additional concerns or comments, please note them below: