Speech-Language Evaluation Intake Questionnaire
This form is for parents or guardians to fill out necessary information related to their child's speech and language evaluation. It includes sections on personal information, medical history, and concerns regarding communication. Completing this form will help facilitate a comprehensive evaluation at Boston Children's Hospital.
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How do I fill this out?
To fill out the form, start by entering your child's basic information including name and date of birth. Next, provide details about your child's family and any specific concerns regarding their speech and language development. Finally, complete the medical history section to give healthcare professionals a holistic view of your child's needs.
How to fill out the Speech-Language Evaluation Intake Questionnaire?
1
Start by entering the child's personal information.
2
Provide family information and any concerns.
3
Complete the medical history section.
4
If applicable, mention hearing and feeding history.
5
Submit the form through the specified channels.
Who needs the Speech-Language Evaluation Intake Questionnaire?
1
Parents seeking a speech-language evaluation for their child.
2
Teachers recommending students for speech assessments.
3
Therapists collaborating with the hospital for evaluations.
4
School administrators needing documentation for evaluations.
5
Healthcare providers monitoring a child's developmental progress.
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Make necessary changes and updates to the document.
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Review the edited content to ensure accuracy.
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What are the instructions for submitting this form?
To submit this form, first complete all required fields accurately. You can send the finalized document via fax or mail to your preferred Boston Children's Hospital location. For Lexington, send to 482 Bedford St, Lexington MA 02420, fax 781-216-2900. For Peabody, mail to 10 Centennial Dr, Peabody MA 01960, fax 781-216-3597. For Waltham, use 9 Hope Ave, Waltham MA 02453, fax 781-216-2252. Review your entries before submission for quality assurance.
What are the important dates for this form in 2024 and 2025?
Currently, there are no specific important dates associated with the use of this form for 2024 and 2025. For any upcoming changes or relevant deadlines, please consult Boston Children's Hospital periodically. Ensure that your submission is timely to avoid any delays in scheduling evaluations.
What is the purpose of this form?
The purpose of this form is to collect comprehensive information regarding a child’s speech and language development to assist healthcare professionals in providing effective evaluations. It gathers crucial data from parents and guardians about the child's background, family history, and specific communication concerns. This enables a tailored approach to treatment and intervention options necessary for the child's growth.
Tell me about this form and its components and fields line-by-line.
- 1. Child's Name: The full name of the child.
- 2. Date of Birth: The child's birthdate.
- 3. Referred By: The individual or entity referring the child for evaluation.
- 4. Home Address: The residential address of the child.
- 5. Language Concerns: Specific language-related issues or questions.
- 6. Family Information: Details about people living in the household.
- 7. Medical History: Relevant medical background of the child.
- 8. Hearing Status: Information regarding the child's hearing ability and history.
- 9. Feeding History: Information on any feeding-related difficulties.
What happens if I fail to submit this form?
If you fail to submit this form, your child may experience delays in receiving essential evaluations. Timely submission is critical for appropriate scheduling and assessment by medical professionals. It is important to provide comprehensive and accurate information to ensure the evaluation meets the child's needs.
- Delay in Evaluation: Late submission may postpone critical assessments.
- Incomplete Information: Missing details can affect the thoroughness of the evaluation.
- Potential Additional Appointments: You may need extra visits to complete evaluations if the form is not fully filled out.
How do I know when to use this form?
- 1. New Evaluations: When a child is being evaluated for the first time.
- 2. Ongoing Assessments: For families seeking follow-up assessments.
- 3. Referral Documentation: When required by educators or other healthcare professionals.
- 4. Pre-Assessment Preparation: For gathering crucial preliminary information for before an evaluation.
- 5. Insurance Processes: As part of documentation required by insurance before treatment.
Frequently Asked Questions
How do I access this form?
You can access this form directly from the hospital's website or through PrintFriendly.
Can I save my changes?
Currently, you can edit and download the form without the option to save changes on the site.
What if I have questions while filling out the form?
Feel free to reach out to the designated contact numbers provided in the form for assistance.
Is there any cost associated with the evaluation?
Costs may vary; please consult your healthcare provider or hospital for specific billing information.
What should I do if I need more information?
Contact Boston Children's Hospital directly for further inquiries regarding the evaluation process.
How do I submit this form?
You can submit the completed form via fax or mail to the preferred Boston Children's Hospital location.
What if my child has special needs?
The evaluation process accommodates children with special needs; please provide relevant details in the form.
Can I fill this form out online?
This form can be filled out digitally using our PDF editor before downloading it.
When will I receive feedback after submission?
Feedback timelines vary; please check with your chosen hospital location for specific turnaround times.
What if I realize I've made a mistake after submitting?
You can contact the hospital to correct any errors or provide additional information.
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