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Micaela.Fisher@smilingstar.net
Phone/Fax: 630.455.4400
406 S. Grant Street (side entrance along 4th street)
Hinsdale, IL 60521

Contact Questionnaire*

Name:*
Address:
Phone:*
Email:*
Insurance Carrier:

Age of your child:

  birth-12 months 13-24 months 25-36 months
  3-5 years 5-8 years over 8 years old

 

 

Area(s) of concern regarding your child:

  Articulation/speech Feeding
  Language Development Voice
  Stuttering  
 
Other    

Has your child ever received services for:

  Speech therapy Occupational therapy
  Physical therapy Developmental therapy

Does your child have a medical diagnosis, which may be impacting his/her communication skills
(e.g. Down Syndrome, Cerebral Palsy, hearing impairment, etc.)?

  No    
  Yes

Articulation/Speech: How much of your child's speech can you understand?

  0-10% 10-25% 25-50%
  50-75% 75-90% 90-100%

 

 

Language: My child can say:

  0-5 words 5-20 words 20-50 words
  Single words 2-3 word utterances short, simple sentences

 

 

Feeding: Does your child have difficulty with any of the following?

  Drooling Sleeping Snores
  Picky eater Weight loss/lack of weight gain Chewing
  Frequent Vomiting Feeding Self Swallowing
  Moving Tongue Sucking Breathing
  Food Allergies Gagging/Choking Other

 

Other Areas of Concern/Comments:

*Please fill out all applicable areas to the best of your knowledge to help me determine how I can meet the needs of you and your child. Thank you!