Contact us.(405) 537-4471monica@languagelionstherapy.com Child's Name * Enter Name First Name Last Name Child's Birthday * MM DD YYYY Parent/Guardian Name * First Name Last Name Parent/Guardian Phone Number * (###) ### #### Parent/Guardian Email Address * What are your speech concerns? * Who referred you to Language Lions? Primary Insurance Carrier * Does your child have a medical diagnosis? * Does your child take any medications? * Who is your Pediatrician/Physician? * Has your child previously received speech therapy services? (Please include where, when, and how long) * Did the child’s mother have any illnesses or complications during pregnancy or delivery? Please describe: * At what age did your child produce his/her first word? * Did your child have any feeding problems as an infant? Please describe: * Please describe illnesses, hospitalizations, or surgeries that your child has had and when they occurred: * Is there a family history of speech-language or other developmental delays? * Has your child had any ear infections? (If so, how many?) * Has your child had his/her vision/hearing tested? What were the results? * Please describe your child's personality & what toys/games they enjoy. How does your child interact with other children? * Please check if you have read the following: * These can be found on the Policies page Cancellation Policy Financial Policy Patient Etiquette Thank you for submitting your patient intake form. We will be in touch shortly.
