The following information is for professional use and will be handled confidentially. This information will assist the speech language pathologist in completing your child’s evaluation.Please complete the following questions as fully and accurately as possible. If you are unable to complete a question, please leave it blank or you may call our office for assistance at (678) 705-1221.
Prenatal and Birth History
Please indicate the age or approximate age at which the following occurred:
Vocabulary of approximately 50 words:
Please answer “yes” or “no” or “sometimes” to the following questions:
Please enclose a copy of the child’s most recent IEP or IFSP and Therapy goals from each area that is checked:
What other services is your child currently receiving both in-school and out of school?
By typing your full name/initials and date, you are signing this consent form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this consent form. You also represent that you are authorized to provide consent for the client whom this document is in regards to.
Thank you for taking the time to complete this form.
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