Intake Questionnaire

PLAYING WITH WORDS

If you have already registered for the Playing with Words workshop, please submit this form prior to your first session. We ask these questions so we can better customize the class to fit your child's needs - thank you!

1. Has your child ever been tested for a speech or language delay?

Yes

If yes, what were the results?

2. Does your child currently receive any other speech-language services? Privately, through a school district or through the San Andreas Regional center?

Yes

If yes, when did they start and how often do they participate in these services?

3. What concerns do you have about your child's language development?

4. Please share what you and your child hope to gain from this class:

5. I signed up for the Playing with Words workshop because: (select all that apply)

I have concerns about my child’s speech and language development (i.e. “I notice other kids their age talking more than they do")

I am looking for ways I can help support my child’s speech and language skills

I am looking for a weekly activity to participate in with my child

I am looking to form friendships with other parents and children that are my child’s age

Other

Your form has been submitted, thank you!

INTAKE QUESTIONNAIRE

PLAYING WITH WORDS

"Building language

through play"

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