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Why Epicenter?
Autism Assessment
Practicum Program
School
216.508.4050
Contact Us
Why Epicenter?
Autism Assessment
Practicum Program
School
216.508.4050
Contact Us
Services
Insurance
About Us
Career Opportunities
FAQs
Blog
Schedule a Consultation
Services
Insurance
About Us
Career Opportunities
FAQs
Blog
Schedule a Consultation
Home
Services
Insurance
About
Career Opportunities
FAQs
School
Blog
Contact Us
Why Epicenter?
Autism Assessment
Forms
Parent Enrollment Agreement
Release of Information
Speech and Language Intake Form
Parent Monthly Signature Form
2026-2027 Parent Handbook
Home
Services
Insurance
About
Career Opportunities
FAQs
School
Blog
Contact Us
Why Epicenter?
Autism Assessment
Forms
Parent Enrollment Agreement
Release of Information
Speech and Language Intake Form
Parent Monthly Signature Form
2026-2027 Parent Handbook
Speech and Language Intake Form
Child’s Information
Full Name
Date of Birth
MM slash DD slash YYYY
Language(s) Spoken at Home
Primary Language
Last Hearing Check
MM slash DD slash YYYY
Last Hearing Check Results
Speech and Language Intake Form
Was the pregnancy full-term?
Yes
No
If not, how many weeks gestation was your child born at?
Were there any complications during pregnancy or birth?
Yes
No
If yes, please describe:
2. Has your child been formally diagnosed with a speech or language delay or disorder?
Yes
No
If yes, please specify:
3. At what age did your child begin doing the following (estimate if unsure)
Babbling: (typically 4-10 months)
First words: (typically 12 months)
Combining 2–3 words: (typically 18-30 months)
Using full sentences: (typically 3-5 years old)
Add
Remove
4. Which of the following best describes your child’s current communication abilities?
No verbal/speaking communication
Single words
2–3 word phrases
Full sentences
ses AAC (e.g., tablet with communication app, PECS, sign language)
5. Does your child struggle with any of the following? (check all that apply)
Making eye contact
Responding to their name
Following simple directions
Expressing wants/needs
Understanding others
Speech sound production (being understood by others)
6. How well do you understand your child?
Always
Most of the time
Sometimes
Rarely
7. How well do others (outside the family) understand your child?
Always
Most of the time
Sometimes
Rarely
8. Does your child: (check all that apply)
Omit sounds (e.g., “ca” for “cat”)
Substitute sounds (e.g., “wabbit” for “rabbit”)
Distort sounds (e.g., unclear “s” or “r”)
Use a lot of unintelligible words
9. Does your child have any of the following oral habits? (check all that apply)
Thumb/finger sucking
Pacifier use
Mouth breathing
Tongue thrust (pushing tongue forward through front teeth)
Bottle drinking
Until what age?
Until what age?
Until what age?
10. Are there any concerns from teachers, caregivers, or pediatricians about your child’s speech and language?
Yes
No
If yes, please describe:
11. Has your child ever received speech or language therapy?
Yes
No
If yes, where and when?
12. What are your main communication goals or concerns for your child?
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