Intake Questionnaire - Erica Goss-Goldstein - Speech, Language & Feeding Therapy

Day of Your Consultation

On the day of your initial consultation please bring the following items:

Preferred drink with a straw
Soft food (i.e., banana)
Crunchy dissolvable (e.g., veggie sticks, cheese puffs)
Chewy food (e.g., bagel)
Puree (e.g., purred food, yogurt, pudding)
A food that you consider to be a challenge food for your child

If your child has a limited food repertoire, bring a variety of foods that he/she eats.

Please bring utensils, cups and straws that the child is using.

Please bring a few photographs of your child (from birth to present). This will assist me in charting muscle development. I will keep one for my file.

Please Note

The information in this form cannot be saved for later. Please be prepared to finish the form in one sitting. It will take approximately 20 minutes to fill out.

Today’s Date *

Relationship to Child *

Information Provided by *

Child's Name *

First

Last

Date of Birth/Age *

Mother's Name *

First

Last

Occupation *

Father's Name *

First

Last

Occupation *

Address *

Full address (including apartment, suite or building Number, if applicable)

Phone Number

Email *

Pediatrician

Referral Source

Other evaluations or interventions

i.e., speech within the school, physical and /or occupational therapy)

Siblings and their ages. Please note if they have any speech/language history.

Please describe any concerns regarding your child’s speech, language, and/or feeding development and when they were first noted.

Is your child adopted?

from other breather?

Length of pregnancy

Describe pre-peri-post natal histories and any problems that may have occurred before, during, or after delivery.

APGAR Score

Seizures

Neonatal Intensive Care

Breathing problems

Suck/Swallow difficulties

Jaundice

Describe your child’s general health condition

Describe any hospitalizations, accidents, serious illnesses, and medications.

Visual Problems/Glasses?

History of Ear Infections/Hearing Loss

Has there been a recent audiological evaluation or screening?

At what age did your child sit?

At what age did your child crawl?

At what age did your child walk?

Has your child established hand dominance?

Is your child well coordinated or does he/she fall frequently?

Is your child toilet trained? If yes, at what age?

Has there been any bed wetting?

Describe any feeding/eating difficulties

Is there any evidence of drooling?

Can your child blow kisses/bubbles?

Can your child stick out their tongue?

Does your child dislike being touched on his/her face?

Is your child a mouth breather?

How would you describe your child during the first year of life (i.e. quiet, noisy, average?)

At what age did your child start babbling:

Say their first words (other than mama/dada)? provide an example

Say two word combinations? Provide an example.

Use complete sentences? Provide an example.

Did speech development appear to stop for a period of time? If yes, explain.

Are you able to understand your child’s speech?

Can unfamiliar listeners understand your child's speech?

How does your child communicate his/her wants and needs?

Is there any evidence of stuttering or voice difficulties?

Does your child respond to his/her name consistently?

Follow simple directions consistently?

Are there any other languages spoken in the home?

Is your child a picky eater? If yes, explain

Does your child have a difficult time managing food?

Does your child feed him/herself?

How long does it take your child to eat a meal?

Does your child drink from a cup?

Does your child drink from a straw?

Please describe your child’s eating habits.

Grade:

Has your child undergone any other evaluations?

(i.e. child study team evaluation, developmental pediatrician, neurological) if yes, explain.

How does your child interact with the other children? Describe.

Does your child have difficulty concentrating or paying attention? If yes, explain.

What are your child’s favorite toys/activities?

If there is any additional information which you feel will help in understanding your child, please describe.

By checking this box, I agree to the payment policies outlined below.

Payment Policy:

Thank you for choosing for us for your speech-language and feeding needs. This is an agreement between Goss Speech, language & Feeding P.C. and you for payment of services provided by Erica Goss Goldstein M.A., CCC-SLP. By signing this agreement, you are agreeing to pay for all services provided to you or your family member.

Please read the following information carefully.

Goss Speech Language & Feeding P.C. does not bill insurance for evaluations and treatment. We will provide you with the information you need to submit a bill to your insurance company. Payment of services is expected at the time of services.

Payment Information:
Please be aware: 45-minute sessions are 40 minutes of direct therapy and 5 minutes for discussion and notes; 1 hr. sessions are 50minutes of direct therapy and 10minutes for discussion and notes.

Travel:
Travel rate for attendance to all out-of-office meetings, trainings, consultations, and home-visits is $100.00 per hour of travel.
We accept cash, checks, chase pay and Zelle (ERICAGOSS@GMAIL.COM) . Please make checks payable to “Erica Goss Goldstein” and indicate the dates of service you are paying for on the memo line. We are happy to talk about other payment arrangements, if needed. Please talk to us ahead of time, and don’t wait until you are not able to make a payment.

Cancellation Policy:
We require 24 hours notice for canceled sessions so that we may accommodate others in need of our services. For sessions canceled with less than 24hours notice, you will be charged the full session rate.
Exceptions will be made when weather makes it unsafe to travel and for emergencies.

Holidays:
Goss Speech Language & Feeding does not follow an academic calendar. Please do not assume that we are closed on school holidays. All sessions will follow a regular schedule unless prior arrangements have been made.

Day 1: Breakfast

Day 1: Morning Snacks

Day 1: Lunch

Day 1: Afternoon Snacks

Day 1: Dinner

Day 1: Evening Snacks

Day 2: Breakfast

Day 2: Morning Snacks

Day 2: Lunch

Day 2: Afternoon Snacks

Day 2: Dinner

Day 2: Evening Snacks

Day 3: Breakfast

Day 3: Morning Snacks

Day 3: Lunch

Day 3: Afternoon Snacks

Day 3: Dinner

Day 3: Evening Snacks

Day of Your Consultation

Please Note

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