Child Case History Form Please enable JavaScript in your browser to complete this form.What best describes your child's current status with us: *Current ClientReturning ClientNew ClientUnsureCurrent or returning clients will not be required to provide detailed contact & address informationChild's First Name *Child's Last Name *Child's Date of Birth *DD12345678910111213141516171819202122232425262728293031/MM123456789101112/YYYY202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Child's Gender *MaleFemaleGender XI'm seeking the following services for my child: *Speech Language TherapyOccupational TherapyCheck all the services you are applying for.Please provide the name & email for your primary contact:Parent/Guardian 1 Full Name *Parent/Guardian 1 email address *Parent/Guardian 2 Full NameOptionalParent/Guardian 2 email addressOptionalAs a Returning Client, would you like to update your address?YesNoAs a Current Client, would you like to update your address?YesNoAddress *Address Line 1Address Line 2CityState / Province / RegionPostal CodeAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Province of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountryAs a Returning Client, would you like to update your phone number(s)?YesNoAs a Current Client, would you like to update your phone number(s)?YesNoPrimary Phone *Secondary PhoneDoes your child have siblings? *YesNoPlease list your child's siblings along with their ages.First name of sibling 1, age; first name of sibling 2, age, etc.Who referred your child? *DoctorParentRelativeTherapistTeacherFriendSelfOtherPlease choose all that apply.REASON(S) FOR REFERRALCheck all that applySPEECH / VOICE, Difficulties with:Speech sounds / enunciationTongue ThrustLispStutteringGeneral Voice (nodules, hoarse, overuse)LANGUAGE / COMMUNICATION, Difficulties with:Interaction and engagementUsing language (expressive language skills)Understanding language (receptive language skills -directions, basic concepts)SOCIAL LANGUAGE SKILLS, Difficulties with:Social skillsMaking and sustaining friendshipsPlay skills and engagement with othersCommunication and anxietyOccupational Therapy Referral *Please list any reasons for your child's referral and your main concerns that you would like us to address.Physician and/or other Healthcare Professional(s) who have seen your child:Doctor, Speech Language Pathologist, Occupational Therapist, Physical Therapist, Dentist, Orthodontist, Registered Nurse, etc.SPEECH LANGUAGE HISTORY OF YOUR CHILDChild's first language *Other languages spoken in the homeHas your child had their hearing tested? *YesNoHas your child ever had Speech Language Therapy? *YesNoLocation & year(s) Speech Language Therapy was provided: *Does your child enjoy or avoid the company of other children? *Generally enjoysGenerally avoidsDoes your child make eye contact with you when speaking or interacting with others? *Yes, alwaysFrequentlySometimesRarelyNoIs your child aware of, or frustrated by, any speech/language difficulties?Please describe your concerns regarding your child's communication *What are your child's strengths? *What are your child's interests? *Has your child accessed Occupational Therapy before? *YesNoUnsureWhere has your Child had Occupational Therapy before? *Please describe the Occupational Therapy services your child received: *BIRTH/MEDICAL HISTORYHas your child had any surgeries *YesNoUnsurePlease indicate any surgeries your child has undergone in the past: *Does your child use any equipment? *YesNoSuch as a walker, wheelchair, AFO's, adaptive utensils etc.Please list equipment or utilities used by your child: *Has your child had their vision tested? *YesNoDoes your child have any health concerns you are aware of? *YesNoHas your child had any serious illnesses or injuries? *YesNoHas your child had any of the following? *AdenoidectomyAllergiesBreathing difficultiesEar infectionsEar tubesFluEncephalitisHead injuryHigh feversSeizuresMeningitisSinusitisSleeping difficultiesTonsillectomyTonsillitisVision problemsChicken PoxN/APlease list any medications your child takes regularlyBIRTH/DEVELOPMENT HISTORYWere there any complications during the pregnancy or birth?YesNoPlease describe the complications experienced during pregnancy or birthPlease provide the approximate age in months your child achieved the following developmental milestonesSat aloneBabblesSaid first wordsPut two words togetherSpoke in short sentencesGrasped a crayon or pencilWalkedToilet trainedDoes your child drink from an open cup? *YesNoDoes your child use a spoon and/or fork? *YesNoDoes your child choke on food or liquids? *YesNoDoes your child play with a variety of toys? *YesNoDoes your child currently put toys/objects in their mouth? *YesNoDoes your child brush their teeth and/or allow you to help them brush? *YesNoDoes your child dress themselves? *YesNoDoes your child undress themselves? *YesNoCheck all that apply to your child: *Difficulty calming when upsetFrequent tantrumsPoor attention spanFussy eaterDifficulties with transitionsDifficulties with following family routinesMouths objectsSeems to be ‘on the go’ (fidgets, wiggles, difficulty sitting still)Seeks movement (spins, rocks, jumps more than others)Dislikes hair washingAvoids messy play or certain textures with their handsEnjoys messy playSensitive to noises (e.g. cries, runs, covers ears)Avoids wearing certain textures of clothingAppears clumsy Dislikes playground equipment N/ASCHOOL HISTORYDoes your child attend school? *YesNoSchool name and grade they're currently enrolled in *Please indicate which therapy services your child may have received at school:Speech-Language TherapyOccupational TherapyPhysical TherapyUnsurePlease provide any additional information you feel may benefit your child's therapy.SUBSCRIBE to our periodic NEWSBITES for updates, tips & happenings!SubscribeThank you for taking the time to fill out our Child Case History FormHow did you hear about us? *Family or FriendsCo-workerFacebookTwitterLinkedInInstagramNews articleRadio/TVWeb search resultsOtherPlease choose all that may have contributed to you choosing us.Who can we thank for your referral?PhoneSubmit