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Rachel Madel Speech Therapy Inc.
Home
About
Meet Rachel
Meet Our Team
Courses
Blog
Videos
Podcast
Resources
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Core Words
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Menu
Intake Form
Child Name
*
First Name
Last Name
Child Date of Birth
*
Parent # 1 Name:
*
Parent #1 Email Address:
*
Parent #1 Phone Number:
*
Parent #2 Name:
*
please put n/a if not applicable
Parent #2 Email Address:
*
please put n/a if not applicable
Parent #2 Phone Number:
*
please put n/a if not applicable
Home Address:
*
School
*
Grade
*
Email Address to Send Billing Invoice to:
*
Insurance Company
*
Do you plan on submitting insurance claims?
*
Yes
No
Medical Diagnosis (if any)
*
please put n/a if not applicable
Allergies (if any)
*
please put n/a if not applicable
Medications (if any)
*
please put n/a if not applicable
Supplements (if any)
*
How does your child sleep?
*
Is your child a mouth breather?
*
Yes
No
Has your child ever demonstrated aggressive behavior?
*
Yes
No
If YES, please explain in more detail:
Is your child using any type of assistive technology?
*
Yes
No
If yes, what technology are they using?
Has your child received a speech/language assessment before?
*
Yes
No
If Yes, when was the most recent assessment?
*
please put n/a if not applicable
Are you currently seeing another SLP?
*
If so, how frequently?
Does your child have an IEP?
*
Yes
No
Screentime for Entertainment
Does your child have sensitivities around screen time or devices? Does your family have specific guidelines or restrictions around screen time? Generally how much screen time/day does your child have access to?
My preferred communication method to discuss my child's progress is:
*
Please mark only one method
Email
Text Message
Phone Call
Video Clips of my Child's Session
How Often I'd like to Receive Progress Updates
After Every Session
Weekly
Monthly
Only when something significant comes up
Contact Info for Progress Updates
*
Please include email/cell according to your preference
My child is motivated by:
*
(e.g. any toys, sensory activities, foods)
If I could change one thing about my child's communication it would be...
*
Are you open to telepractice?
*
This does not necessarily mean we will work with your child directly, it also includes virtual consults, coaching and team collaborations!
Yes
No
I was referred by:
My child's disposition:
*
How well do they work with new people? Is there anything specific we can do to make them feel safe and comfortable?
Availability for therapy
*
Please include ideal number of sessions as well as days/times your child is available. Don't forget to include multiple locations (e.g. school vs. home) as well as relevant notes (e.g. nap times/other therapies etc.) Please put n/a if you are not interested in regular therapy.
Thank you!