CENTER FOR CHILDHOOD COMMUNICATION
DEPARTMENT OF SPEECH-LANGUAGE PATHOLOGY
Thank you for your interest in speech-language pathology services at The Children’s Hospital of Philadelphia.
Outpatient speech and language evaluation and therapyservices are provided at several locations:
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-Pennsylvania: Main Campus in Philadelphia (Buerger Center for Advanced Pediatric Care, 5th Floor), Brandywine Valley (Glen Mills), King of Prussia, Exton, Bucks County (Chalfont)
-New Jersey: Voorhees, Mays Landing (Atlantic County), and Princeton at Plainsboro
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Please read this entire letteras it contains important information regarding your child’s appointment.
Prior to requesting an appointment, please complete theenclosed Speech and Language Evaluation Questionnaire.This allows us to accurately schedule the evaluation and provides the speech-language pathologist with your child’s medical, developmental, and educational history. Additionally, please forward copies of other records pertinent to a speech and language evaluation (e.g., hearing test results, reports from psychologists, neurologists, and developmental pediatricians, previous speech-language evaluations, and educational reports such as IEPs, IFSPs, etc.). Please fax the completed questionnaire and other relevant records to 267-426-5934, or mail it to:
Speech Intake Coordinators
The Children’s Hospital at The Wanamaker Building
100 Penn Square East
6th Floor – Access Center
Philadelphia, PA 19107
Always keep a copy of these documents for your own records. Once we receive the evaluation questionnaire and any related documents, a scheduler will call you to set up an appointment.
Information about your child’s evaluation
During theevaluation, our speech-language pathologist will perform an assessment of your child’s ability to understand language, expressively communicate, and use his/her voice to speak clearly and fluently.
At the end of the evaluation, we will give you information about your child’s speech and language abilities, appropriate medical, educational and community resources to meet your child’s further assessment and therapeutic needs, home programming ideas, and recommendations and goals for therapy.
If hospital-based therapy services are recommended as a result of the evaluation, please be aware that we follow a “medical therapy model.” As a result, we are primarily a diagnostic center with a focus on evaluation services and a commitment to helping families understand treatment options for their children. Short-term therapy is available, when appropriate, with the goal of transitioning services to educational and community settings that will be able to meet your child’s long-term therapeutic needs if necessary.
Appointment guidelines
-Please arrive 15 minutes prior to your scheduled appointment to complete the registration process
-Allow up to 90 minutes for the completion of the evaluation
-Your child must be accompanied to the evaluation by a parent or legal guardian
-In an effort to obtain the best attention from your child and assessment of his/her skills, it is preferable that siblings do not accompany your child to the appointment
-Please make sure you understand and comply with your insurance benefits, coverage limitations and requirements, including co-payment, referral, prescription coverage, etc.
Any questions you may have will be answered by the speech-language pathologist at the time of the evaluation or thereafter. We look forward to meeting you and your child.
THE CHILDREN’S HOSPITAL OF PHILADELPHIA
CENTER FOR CHILDHOOD COMMUNICATION
DEPARTMENT OF SPEECH-LANGUAGE PATHOLOGY
SPEECH AND LANGUAGE EVALUATION QUESTIONNAIRE
Please complete and return this questionnaire, using black ink. The information will be used to assist in the proper scheduling and evaluation of the child. All information will be kept confidential.
Person filling out this questionnaire Relationship to child
Who referred you to this facility?
Please √ appointment type needed:Initial/New Evaluation (never seen by CHOP speech)
Re-evaluation (seen by CHOP speech before)
√ preferred location(s) for evaluation: Next available/Any site
NJ Voorhees Mays Landing Princeton at Plainsboro
PA CHOP (Phila) Chalfont Exton King of Prussia Brandywine Valley
Has the child had a hearing test within the past year (circle)? YES / NO
Language(s) spoken at home
Interpreter needed:For parent(s)? Yes / No What language?
For child? Yes / No What language?
Child’s nameBirth date
AddressAge
Sex
ParentParent
AddressAddress
Home phoneHome phone
Marital status Marital status
Age______Age
Education______Education
Occupation ______Occupation
Employer______Employer
Work phone______Work phone
Cell phone______Cell phone
Email______Email______
Name of child’s physician/practice Phone
Primary Insurance Secondary Insurance
Names, ages and relationships of those living in the child’s home:
NameAgeRelationship to child
______
______
______
______
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PRIMARY CONCERNS
What are the primary concerns you have about the child’s speech, language or voice?
In which of the following areas does the child seem to have difficulty? Check all that apply.
______Hearing sounds______Voice difficulties
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______Understanding what others say
______Saying speech sounds
______Learning and using new words
______Using sentences
______Stuttering
______Feeding
______Other (Please describe)
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Who first noticed the problem(s)? When?
Apart from speech, language and hearing, are there concerns about the child’s development in other areas (e.g., coordination, play skills, making friends, cooperativeness, self-help skills such as toileting and dressing, general activity level)? Please describe.
BIRTH HISTORY
Was child adopted? If so, from where and at what age?
Were labor and delivery normal?Type of delivery?
Was the child premature? Length of pregnancy? Birth weight
Were any of the following used by the child’s mother during pregnancy?
Cigarettes Alcoholic drinks
Prescribed drug
Nonprescribed drug
Did the mother experience any illnesses, accidents or injuries during the pregnancy? Please describe.
______Which trimester
______Which trimester ______Which trimester
Please describe any medical problems the child had during the first few weeks of life (e.g., jaundice, seizures, breathing difficulties, feeding difficulties, etc.).
Did the child pass the newborn hearing screening? Yes No
How long did the child stay in the hospital following birth?
MEDICAL HISTORY
Has the child had any of the following conditions?If so, please note how old the child was when the condition occurred and if it is a continuing problem.
ConditionAge(s)ConditionAge(s)
Allergies______Head injury______
Asthma______Heart disease______
Chronic colds______High fever______
Cytomegalovirus (CMV)______High Lead Level______
Ear infection______Meningitis______
Encephalitis______Seizure______
Other: please list
Has the child ever been hospitalized for treatment of an illness or accident? Please describe and give dates.
Has the child ever had surgery (please describe and give dates)?
Has the child been examined by the following specialists? List dates and results and attach reports.
SpecialistDateFindings/Agency
____Allergist______
____Audiologist (hearing)______
____Cardiologist (heart)______
____Developmental Pediatrician______
____Geneticist______
____ENT (ear/nose/throat)______
____Neurologist ______
____Ophthalmologist (vision)______
____Orthopedist______
____Psychiatrist ______
____Psychologist______
____Other ______
Please list any medication(s) the child takes regularly.
MedicationReason
______
______
______
Does the child currently have or use:______Other adaptive equipment (e.g., wheelchair)
______Eyeglasses______Bottles
______Hearing aid(s)______Pacifier
______Dental braces______Sippy cup
______Oral appliance______Spoon
______Assistive communication device______Thumb sucking/finger sucking
Is the child considered a picky eater? If so, please list the child’s food preferences:
FAMILY HISTORY
Please list any of the child’s relatives having the conditions listed below (e.g., hearing loss/grandfather).
Mental retardation/IntellectualDisability Autism/PDD
Developmental Delay Speech/language problem
Cleft palate Reading problem
Other birth defect Learning disability
Hearing loss Other:
DEVELOPMENTAL/COMMUNICATION HISTORY
At approximately what age did the child: Walk alone Become toilet trained
Begin to babble? (e.g., bababa, dadada, gagaga, etc.) Did it seem normal?
First produce atrueword (e.g., “ball”, “car”, “truck”)? What was the word?
Begin to say two or more words in a sentence, such as “baby down”; “more juice”?
Does the child follow simple spoken directions?
How many words do you think the child uses (says)? (You can estimate)
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Does the child speak: Often Sometimes ______Rarely Never
Does the child become frustrated when not understood: Often ______Sometimes ______
Rarely ______Never ______
What percent of the time does the family understand the child’s speech?
What percent of the time do strangers understand the child’s speech?
Has the child ever spoken better than he or she does now? Please explain.
Does the child’s speech ever seem to get better or worse? Please explain.
Has the child ever had a speech and language evaluation? If so, where?
When? Results?
Has the child ever had speech and language therapy? If so, where?
When? How often?Still Receiving?
Goals/Results?
EDUCATION
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Name of school or day care
Days and times child attends school or day care
School DistrictGrade in School
Previous school attended ______Date ______Ages
Previous school attended ______Date ______Ages
If the child attends school or daycare, does the family or teachers have concerns about the child’s performance? If so, please describe them here.
Has the child ever received testing? ______When?
What type(s) of testing were completed?
Where was testing completed?
Please describe the results of testing: (Please attach copies of any available testing reports, IEP, etc.)
Has the child ever repeated a grade? ______If yes, which grade?
What was the reason for repeating?
Check all special services that the child has received or is currently receiving:
Please send a copy of relevant reports with this questionnaire to the Intake Coordinators or bring to the evaluation.
Early Intervention What services?
Intermediate Unit What services?
Special Class (e.g., Learning Support, Life Skills, Autistic Support) Type?
Tutoring Where? In what subjects?
Resource Room For what subjects?
Occupational Therapy Goals
Physical Therapy Goals
Vision Therapy Goals
Hearing Therapy Goals
Other Services Goals
OTHER
What play activities does your child enjoy?
Have any significant changes occurred in the child’s family during the last few years (e.g., deaths, serious illnesses, separations, divorces, moves, etc.)? Please describe.
Is there any other information that might be helpful to us in understanding and assessing the child?
If so, please describe.
Your signature ______Date
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