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Sarah Kono, Speech
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Contact Sarah
Home
About
Services
FAQ’s
Testimonials
Contact Sarah
Speech Background Intake Form
Please fill this out so I can get a better idea of your child and your family's needs
Parent or Guardian Information
First Name
Last Name
Phone Number
Email Address*
Address
Child's Information
Child's Name
Child's DOB
Please list any diagnosis and/or prior surgeries
Grade
Pre-K
K
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
What school does your child go to?
Does he/she get Speech at school?
Yes
no
in the process of being evaluated
Was evaluated, but didn't quality
Other Services Received
OT
PT
ABA
Other
If your child has been through therapy before, what worked and what didn't?
What brings you here? What is the reason you are seeking speech therapy? Describe your child's speech/language concerns.
When was this concern first noticed?
How does your child communicate?
Gestures
Pointing
Taking partner's hand to desired items
Word approximations
Single words
My child speaks in phrases
What languages are spoken in the home and at school?
If you come from a multilingual household, when did your child become exposed to English?
In terms of receptive language, can your child ID
Numbers
No
Inconsistently
Emerging
Mastered
Letters
No
Inconsistently
Emerging
Mastered
Shapes
No
Inconsistently
Emerging
Mastered
Colors
No
Inconsistently
Emerging
Mastered
Animals
No
Inconsistently
Emerging
Mastered
Vehicles
No
Inconsistently
Emerging
Mastered
Does your child demonstrate frustration? If so, is there a situation that particularly frustrates him/her?
My Child...(choose what applies)
Follow 1-step commands
Follow 2-Step commands
Follow along with the household routines (coming to the table to eat, getting jacket and shoes, etc)
Turn to his/her name
What are goals for your child pertaining to speech?
What does your child like to do? How can I best incorporate your child's interests into my sessions?
Have you had an AAC evaluation?
yes
no
in the process
If you have AAC, what application do you have?
In regards to AAC, I am interested in
Changing the application I have
a home training on the app
Ways to implement the application
Therapy using AAC
Submit