3731 Sixth Avenue, Suite 103
San Diego, California 92103
Phone: (619) 291-3515
Fax: (619) 291-3529
Developmental Therapy Center
General Developmental History
Contact Information
Client Name
Sex
DOB
Date:
Age
Parent(s) Name(s)
Address
City
Email
State
Zip Code
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Home Phone
Work Phone
Cell Phone
School/Day Care Attending
Grade Level/Days per week
Teacher’s Name
School Phone
Siblings(s)/others who live at home (please indicate age/sex)
Languages Spoken in the Home
Referral Source
Medical Diagnosis
Current Medications
Basic Information
Please describe your general concerns regarding your child that brought you here today.
Has your child seen any other specialists or received any services in the past (e.g. occupational therapy, speech therapy,
physical therapy, ABA, special education, counseling, etc.)?
Are there any other speech, language or hearing problems in your family? If yes, please describe.
Were they any complications during pregnancy or delivery?
Please specify the conditions of your child’s birth (e.g. full term, premature, emergency delivery).
Has your child had any surgeries or major injuries/hospitalizations? If so, please explain.
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Developmental History
Does your child have a history of seizures?
How is your child performing in school or daycare?
Feeding
Are there or have there ever been any problems with feeding (e.g. sucking, swallowing, drooling, chewing, reflux)?
Would you describe your child as a picky eater (e.g. avoids colors, textures, temperatures)?
Does your child exhibit oral sensitivities or oral seeking behaviors (e.g. examines object by placing in mouth, gags/vomits
frequently, bites/chews objects or clothing frequently, grinds teeth, etc.)?
Does your child have any food allergies or adhere to any special diet?
Hearing
Does your child have a history of recurrent ear infections? How many? At what ages? How were they treated?
Has your child had any surgeries (e.g. tube placement, tonsillectomy, adenoidectomy)? When?
Has your child had his/her hearing tested? When? What were the results?
Developmental Milestones
Age your child:
Crawled
Stood Alone
Walked
Said first words
Began combining words
Began having conversations
Comprehension
How well does your child understand you? Others?
Does your child respond to inhibitory commands (e.g. no, wait, stop)?
Does your child follow:
 simple commands (e.g. put that away)? Y N
 2-step directions (e.g. get your shoes and brush your hair)? Y N
 3-step directions (e.g. pick up your toys, brush your teeth and get in bed)? Y
Does your child respond to yes/no questions?
Does your child respond to his/her name?
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N
Developmental History
Play/Social
Does your child exhibit functional play (e.g. stacking blocks and knocking them over; opening and closing boxes, dumping
toys)?
Does your child participate in symbolic play (e.g. use a stick to represent a microphone or banana to represent a phone?)
Does your child demonstrate pretend play (e.g. feeding a doll, playing doctor, having a tea party)?
Is your child destructive toward toys (e.g. throwing toys, ripping books, pulling wheels off cars, etc.)?
Does your child have a strong desire for structure or control?
Is your child able to play alone? Is your child able to play with others?
Who does your child typically play with (e.g. older peers, younger peers, siblings?)
How does your child adjust to new environments and individuals?
Does your child babble or talk during solitary play?
Does your child imitate behaviors he/she observed at an earlier time?
Does your child act out common activities (e.g. plays house, plays store, washes dishes)?
What are your child’s favorite toys/activities?
Does your child exhibit aggressive behaviors (e.g. biting, pinching, hitting, scratching, kicking, hair pulling) directed at self or
others?
Sensory
Describe the child’s response to sound (e.g. responds to all sounds, responds to loud sounds only, inconsistently responds to
sounds).
Does your child exhibit repetitive behaviors (e.g. flapping arms, spinning)?
Is your child often frustrated, anxious or overwhelmed?
Are transitions difficult for your child?
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Developmental History
Tells us about your understanding of your child’s condition or development:
Please describe your hopes/dreams for your child and family:
Please describe your fears for your child and family:
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Developmental History
Speech and Language Intake Form
Contact Information
Client Name
Sex
DOB
Date:
Age
Speech-Language Development
Did your child babble during infancy?
At what age were his/her first word(s)? What were they?
Does your child use single words?
Does your child use 2-3 word combinations (e.g. me go; daddy shoe; more juice)?
Does your child use short phrases or sentences?
Does your child ask questions (e.g. Where’s doggie)?
Does your child combine vocalizations with gestures (e.g. pointing + “eh eh eh”)?
Approximately how many real words does your child use consistently?
Communication
How does your child:
 Get your attention (e.g. through gestures, verbalizations, tapping, crying, etc.)?

Express wants/needs?

Express frustration?

Ask for help/toileting needs?
Please circle your child’s primary mode(s) of communication:
gestures/signs vocalizations single words
short phrases
Does your child know how to take turns in conversation?
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sentences
crying/screaming
Developmental History
Comprehension
Approximately how many words would you say your child understands?
Does your child respond to simple ‘what’ questions? Is your child able to respond to other ‘wh’ questions (i.e. who, where,
when)?
Intelligibility
How well can your child be understood by parents? Siblings? Family members/familiar adults? Others?
What do you do if/when you are having difficulty understanding your child? Do you ask them to repeat?
Does your child make errors on specific speech sounds? Which ones?
How does your child respond when not understood (e.g. becomes frustrated, gives up, moves on to something else)?
Does your child compensate by using gestures?
Does your child imitate speech sounds? Immediately? After a delay? How accurate is the imitation?
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