Insurance: Does your child have Medicaid coverage? Yes  No

Please list your child's allergies:
 

Does your child have a diagnosis related to any of the following:
Speech and Language                      Autism                      Anxiety

ADD                                               ADHD

Where does your child attend school? 

What grade is your child in?      Can your child read? Yes   No

Does your child receive speech and language services? Yes   No
If so, how many times per week? 

What is the focus of the therapy? 

Does your child receive counseling services?  Yes No

Does your child have difficulty making or keeping friends? Yes   No

Does your child have difficulty interacting with others?  Yes     No

Does your child interact with peers versus adults? Yes   No
If so, what is the difference? 

Please check any skills that your child needs to learn or practice:

Greetings   Eye contact  Personal Space   Boundaries

Interrupting Conversations      Topic Maintenance   Turn Taking 

Sharing   Cooperating    Joining An Ongoing    Activity Listening

Appropriate Play Appropriate versus Inappropriate Behaviors  

Identifying Feelings  Identifying Energy Levels   Regulating Energy Levels.

Please also write a brief description of your child and his/her difficulties with speech, language, anxiety, and social interactions.

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