Welcome to Beyond-Limits

Speech Therapy Brief Admissions Form

Welcome

About 6 minutes 8 steps Sent securely

Questions marked * are required.

Child Information and Requested Services

For patients currently receiving other services at Beyond Limits.

Services Requested

Please enter a date that is not in the future.
Gender

Evaluation Concerns and Home Language

Is any language other than English spoken in the home?

Therapy Services and Education

Current therapy services your child is receiving

Does your child have an Individualized Education Program (IEP) or Individualized Family Service Plan (IFSP)?
Has your child had a psychological or neuropsychological evaluation completed?

Medical History

Please list allergies or tick No known allergies.

Hearing Test

Please enter a date that is not in the future.

Vision Test

Please enter a date that is not in the future.

Speech Development

Indicate the approximate age at which your child reached the following milestones:

Communication

Does your child prefer to communicate with:
Does your child follow simple directions?
Does your child understand what you are saying?
Does your child identify objects and actions easily?
Does your child respond correctly to yes/no questions?
Is your child’s speech easily understood by most people?
Is your child aware of or frustrated by any speech/language difficulties?

Activities

Parent Signature

Thank you for this information related to your concerns as they relate to speech/language therapy. This allows your evaluating therapist to select the most appropriate assessment tool(s) for your child.