Keri Skipper, MCD CCC-SLP
Phone: 864-406-6769
Email: [email protected]
Web: pathwayspediatrictherapysc.com
INTAKE FORM
Child’s Name: _______________________________________________ Child’s DOB: ____________________
Child’s Gender: Male _______ Female ________
Child’s Social Security Number: _____________________________
Caregivers: ____________________________________ _______________________________________
Concern/reason for referral: __________________________________________________________________
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Referred by: _______________________________________________________________________________
Has your child received therapy before? ___ Yes ____No If yes, when and where? _______________________
MEDICAL HISTORY
Child’s birth weight: _____________ Weeks gestation: _______________
Complications during pregnancy or birth: ________________________________________________________
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Passed newborn hearing screening: ____Yes _____No Concern with hearing: ________Yes ________No
Medical conditions/surgeries: _________________________________________________________________
Daily medications: _______________________________ Allergies: ___________________________________
Specialty physicians: _________________________________________________________________________
Family history of developmental delays/disabilities:______Yes _________No If yes, please explain: _________
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