Intake Form

Does your child understand SINGLE WORDS? (Receptive)(required)

Yes No

Does your child understand PHRASES? (Receptive)(required)

Yes No

Does your child understand SENTENCES? (Receptive)(required)

Yes No

Are they able to identify or point to objects when named? (Receptive)(required)

Yes No

Does your child use SINGLE WORDS? (Expressive)(required)

Yes No

Does your child use PHRASES? (Expressive)(required)

Yes No

Does your child use SENTENCES? (Expressive)(required)

Yes No

Can your child verbally label objects on their own? (Expressive)(required)

Yes No

Does your child have difficulty saying or pronouncing new words?(Expressive)(required)

Yes No

Does your child use VOCALIZAITONS? (Expressive)(required)

Yes No

Does your child use GESTURES? (Expressive)(required)

Yes No

Does your child POINT?(Receptive, Expressive, and Pragmatic)(required)

Yes No

Does your child vocalize, gesture, or point toward desidered objects and/or people?(Expressive and Pragmatic)(required)

Yes No

Does your child look at faces, lips, and mouths when people are talking? (Receptive and Pragmatic)(required)

Yes No

Does your child look at books? (Receptive)(required)

Yes No

When they look at books, are they: (Receptive and Pragmatic)(required)

By themselves? With you? Not applicable

Does your child play with toys? (Play)(required)

Yes No

When they play with toys, do they play in their own way? (Play)(required)

Yes No Not applicable

When they play with toys, do they play in a similar way to other children their age? (Play / Stage of Development)(required)

Yes No Not applicable

When they play with toys, do they put the toy in their mouth or egage in sensory exploration? (Play / Stage of Development)(required)

Yes No Not applicable

When they play with toys, do they play with or beside other children? (Play / Stage of Development)(required)

With (interactively) Beside (separately, but next to others) Not applicable

When they play with toys, do they talk? (Expressive and Play)(required)

Yes No Not applicable