Psycholinguistic Associates Inquiry Form

You may complete this form online and use the Submit button below to send it to Dr. Kemper via email,
or you may print it, fill it out, and mail to:
Psycholinguistic Associates, Inc., 86 Mill Street, Haverhill, MA 01830

Your Email:

Child's Name
Street Address
City/State/Zip
Telephone Number
Child's Age
Date of Birth
Child's Physician
Appointment Date
Who referred you for this evaluation?
For what reason?
Describe in your words what you think the problem is.
List all people living with the child.

Name: Age: Relation to child:

Name: Age: Relation to child:

Name: Age: Relation to child:

Name: Age: Relation to child:

Name: Age: Relation to child:

Name: Age: Relation to child:

Father's Name
Father's Address if different from child's
Father's Occupation
Mother's Name
Mother's Address if different from child's
Mother's Occupation
Parents are: Living together
Separated
Divorced
Widowed
What language is spoken predominantly at home.
If any family members have a physical, emotional, or learning problem, please explain.
If any family members have a communication problem, please explain. Include the name, the kind of problem, and any treatment received.
If any family members are receiving counseling, psychological, or psychiatric treatment, please explain. Include the name, the kind of problem, and the treatment received.
Pre/Peri Natal History *************************************
Was the pregnancy full-term? Yes
No
Was a doctor present at the time of delivery? Yes
No
Did the baby leave the hospital with the mother? Yes
No
Did any bleeding occur during the pregnancy? Yes
No
Were you on any special diets/medications during the pregnancy? Yes
No
Did you have any miscarriages/abortions? Yes
No
Did you have any illnesses during the pregnancy? Yes
No
Were forceps used during the delivery? Yes
No
Was the baby induced? Yes
No
How long did labor last?
Was the baby delivered by cesarean section? Yes
No
Was anesthesia used? Yes
No
Did the baby have any medical problems detected at birth? Yes
No
If the baby had medical problems at birth, please explain.
Please list any illnesses the baby had immediately after birth. If there were hospitalizations, where were they and for how long?
Post Natal History *************************************
If the child had any medical problems or illnesses during the first few months, please list them. If there were hospitalizations, where were they and for how long?
At approximately what age did your child:

Crawl:
Walk:
Begin to use single words:
Combine words:
Speak in complete sentences:

Was the baby active? Yes
No
Was the baby noisy? Yes
No
Medical History *************************************
Has your child had any accidents, serious illnesses, or hospitalizations (other than those listed above)?
For hospitalizations, where and for how long.
Did your child ever have a high lead level? Yes
No
Has your child ever received medication? Yes
No
If your child is receiving medication now, please explain.
Does your child experience difficulty making and keeping friends? Yes
No
Is this child developing differently from your other children? Yes
No
Is your child's speech/language different from the rest of the family? Yes
No
Does your child become frustrated when attempting to communicate (verbally)? Yes
No
If your child has difficulty speaking, is he/she aware of it? Yes
No
Does your child seem to forget the names of common things or events? Yes
No
Does your child seem to have difficulty understanding what is being said around and to him? Yes
No
Does your child's voice sound:
(check one, both, or none)
hoarse
nasal
Does your child frequently repeat sounds, words, or phrases? Yes
No
Does your child prolong words? Yes
No
Does your child frequently hesitate when speaking? Yes
No
Does your child have difficulty with reading and spelling? Yes
No
Does your child have difficulty explaining to you common events such as what happened in school? Yes
No
Does your child show signs of Attention Deficit Disorder (ADD/ADHD)?
(check all that apply)
short attention span
distractibility
high activity level
Hearing *************************************
If there is any history of hearing loss in your family, please explain. Include who has the hearing loss, what kind, and the age of onset.
Does your child have a hearing loss? Yes
No
Do you suspect your child has a hearing loss? Yes
No
If your child has been seen by an ear doctor, please indicate when, why and the doctor's name.
If your child has had ear infections, please indicate the age of onset, medical treatment, and frequency.
Social Behavior *************************************
Is your child shy? Yes
No
Is your child very active? Yes
No
Do you have difficulty disciplining your child? Yes
No
Does your child have temper tantrums? Yes
No
Does your child get along well with children his/her own age? Yes
No
Educational History *************************************
If your child currently is in school, please indicate the school, grade, and teacher.
If your child has ever repeated a grade, indicate which grade.
Please list all the schools your child has attended. Indicate the name of the school, the grade(s), and your child's age in each grade.
If your child has difficulty in school, please explain.
If your child receives, or has received, special help in school, please explain.
For example, special help may include a Resource Room or speech-language therapy.
Indicate the amount of time. For example, 5x/wk for 2 hours.
If your child has a current I.E.P., please indicate the primary/secondary disability.
If your child has ever been evaluated in school, please indicate the type of evaluation, when it took place, and where it took place.
If you child has ever received any of these evaluations, check all that apply and indicate who did the evaluation, where it was done, and the date it was done. Speech/Language

Hearing

Educational

Neurological

Psychological

Other

Insurance Information *************************************
Please provide your insurance ID number. If you are a BC/BS member, include the 3-letter prefix followed by the 10-letter numeric:
Signature [type your name]
I agree to pay all expenses that are associated with this evaluation that are not paid by the school district or insurance including, but not limited to, evaluations, school observations, meetings, mediations, and hearings.
Relation to Child
Date


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