Boston Children's Hospital Speech-Language Evaluation Intake

Please complete this form in its entirety. You will be asked to upload any additional information such as hearing tests or IEPs. Please have those ready prior to beginning the form. With any questions, please contact SpeechProgram@childrens.harvard.edu

Thank you for choosing Boston Children’s Hospital for your child’s speech and language evaluation

This intake questionnaire must be completed before your child’s evaluation can be scheduled. We ask that you complete this form with all pertinent information to ensure that your child receives the most appropriate evaluation.

Please note if your insurance requires pre-authorization and/or a referral, it is your responsibility to make sure this is taken care of before the appointment.

This intake is for a Speech and Language Evaluation

PLEASE NOTE: You are completing this form to request that your child be seen for an evaluation of their speech, language, and communication. This is not a form to request speech-language therapy.

Our diagnostic evaluations are a stand-alone service that are not used as the initiation of therapy. In most cases, when a child needs ongoing therapy, we refer families to services in their community. This may include services through a local early intervention program, the public school system, or local private speech-language pathologists.

While we do offer short-term outpatient therapy services for some children, most therapy through our program does not begin immediately after an evaluation. If your child is appropriate for our short-term therapy services, we will place them on a therapy waitlist after the evaluation has been completed.

If you are seeking evaluation from another program, please follow the instructions below.

Feeding and Swallowing Program, please call 617-355-7727
Augmentative Communication Program (e.g. assistive technology) or the Autism Language Program, please call 781-216-2209
Deaf and Hard of Hearing Program, please call 781-216-2215
For concerns related to your child's voice/vocal quality, please call 617-355-5116

Your child must have had a hearing test with an audiologist before participating in this evaluation

This can be scheduled at any Boston Children’s Hospital location by calling (617) 355-6461. If a hearing test has been conducted outside of this facility, please attach documentation in the appropriate location below. The hearing test must occur with an audiologist - a test at a PCP/pediatrician office is not sufficient.

The scheduling of an evaluation does not guarantee that your child will be seen for therapy.

Please check here to confirm you understand you are completing this intake for an evaluation through the Speech and Language Pathology Program.

This intake form is not for therapy.

Please read the following important information

• No food or drink is allowed in the office or waiting area.

• All shared items/high touch services are sanitized before and after the appointment.

• For an in-office visit, please leave other children at home as you may need to be in the room with your child during the evaluation.

Your appointment will be scheduled based on when the completed intake form is received. Please fill out the entire form and include any supporting documentation as outlined above. We look forward to working with you and your child. Speech-Language Pathology Staff Department of Otolaryngology and Communication Enhancement Boston Children’s Hospital

Patient Information

Prior to starting, please ensure you have all documents needed (IEPs, outside evaluations, etc). This form must be completed and submitted in one sitting. You cannot save progress.

Child's name (first and last)

Child's medical record number (if known)

Date of birth

mm/dd/yyyy

What is the patient's preferred first name or nickname?

What are the patient's pronouns?

Select from drop down or type in

Words are powerful. The words you use and the way you portray individuals matters. If you feel comfortable, please share with us any language/terminology that you prefer related to you/your child's identity, diagnosis, or disability

Home address

Street Address

City

State

Best phone number(s) for contact

Best email(s) for contact

Do you prefer to be contacted by telephone or email?

Questionnaire completed by (your name and relation to child)

Reason for Evaluation

Please state specific questions and concerns - what you are hoping to get from the evaluation

As a reminder, this intake is to request a speech language evaluation, not speech language therapy

This is required to secure an appointment.

Does the patient have a diagnosis of autism?

Yes

Autism will not be diagnosed or ruled out within this speech language evaluation.

If there is not currently a diagnosis of autism and it's suspected, you may wish to also contact the Autism Spectrum Center at 617-355-7493.

Who were you referred by?

Pediatrician/Primary Care Provider

Pediatrician/Primary Care Provider phone number

Pediatrician/Primary Care Provider Address

What is the child's primary language?

Please indicate the language the child hears, understands, and speaks most often

Are any other languages spoken within the home?

Yes

Would you like an interpreter for the evaluation?

This evaluation will be conducted in English. Select "yes" if you would like an interpreter for you or your child.

Yes

Family Information

Please list all people currently living within the household, with their ages and relationship to child

Family History (Select all that apply)

Do any immediate or extended family members have a history of any of the below?

Medical Information

Does your child currently take any medications?

Yes

Is your child followed by any other departments at Boston Children's Hospital or other local medical centers?

Yes

Does the child have any feeding or swallowing difficulties or concerns?

Yes

Does your child have a history of ear infections or middle ear fluid?

Yes

Has your child's hearing been tested by an audiologist?

Yes

Developmental History

Please list the ages at which your child:

Sat independently

Crawled

Walked independently

Babbled

Said first word

Combined two words

Produced sentences

Did your child ever stop talking or stop saying words s/he used to say?

Current communication

Does your child:

Respond to his/her name?

Yes

Sometimes

Point to objects when asked?

Yes

Sometimes

Follow simple directions?

Yes

Sometimes

Get objects from another room when asked?

Yes

Sometimes

Point to body parts when asked?

Yes

Sometimes

Point to pictures in books?

Yes

Sometimes

Answer simple questions?

Yes

Sometimes

Understand prepositions?

e.g. in, under, behind

Yes

Sometimes

Understand color and size words?

e.g. big, little, red

Yes

Sometimes

Engage in pretend/imaginary play?

Yes

Sometimes

Current communication

Please select all of the ways your child currently communicates

Please list examples of child's current communication here

For example, how does your child let you know what they are thinking?

Does your child ignore you when you are speaking?

Yes

Sometimes

Does your child socialize/play with other children?

Yes

Sometimes

Do you or others have difficulty understanding your child's speech?

Yes

Sometimes

Does your child appear frustrated when he/she is not understood?

Yes

Sometimes

Does your child repeat sounds or words when speaking?

Yes

Sometimes

Educational Information

What school or daycare is the child currently enrolled in?

Please include grade and type of classroom (e.g. regular education, special education, integrated). State N/A if not applicable

Do you have concerns about your child's reading or academic progress?

Yes

Please select all services currently being received

Please detail services received - where is the child receiving services, how often, and how is it going?

If your child is receiving therapy currently, what skills are being addressed?

Please select or type in any kind of evaluation your child has had

Please type in the name of any evaluation type you do not see in the list below.

Requested Documents

In order to best serve your child, we need past evaluation reports and other relevant documents. These may include: -Individualized Education Program (IEP) and recent IEP Progress Reports -School speech and language evaluations -Other recent school evaluation report such as psychological, academic/educational, occupational therapy, physical therapy, and behavioral assessments -Neuropsychological evaluation -Early Intervention (EI) evaluation and/or Individualized Family Service Plan (IFSP) -Recent EI therapy notes -Recent outpatient speech and language therapy notes/evaluation -Hearing evaluation report/audiogram (if not conducted at Boston Children's Hospital)

Please upload any files that fit the above list

Drop your files here

Additional Information

What are your child's favorite or preferred activities and toys?

Please tell us anything else that may help us to better understand your child

Insurance Information

Health insurance provider (primary)

Policy holder's name (primary)

Policy number(s) for patient (primary)

Group number (primary)

Health insurance provider (secondary)

Policy holder's name (secondary)

Policy number(s) for patient (secondary)

Group number (secondary)

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