Child's First Name *

Child's Last Name *

Child's Date of Birth *//

Child's Gender *

Male
Female
Gender X

Parent/Guardian 1 Full Name *

Parent/Guardian 1 email address *

Parent/Guardian 2 Full Name

Parent/Guardian 2 email address

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Primary Phone *

Secondary Phone

Sibling 1 Name

First

Last

Sibling 1 date of birth//

Add more siblings?

Sibling 2 Name

First

Last

Sibling 2 date of birth//

Sibling 3 Name

First

Last

Sibling 3 date of birth//

Sibling 4 Name

First

Last

Sibling 4 date of birth//

Who referred your child? *

REASON(S) FOR REFERRAL

Check all that apply

SPEECH / VOICE, Difficulties with;

LANGUAGE / COMMUNICATION, Difficulties with;

Interaction and engagement
Using language (expressive language skills)
Understanding language (receptive language skills -directions, basic concepts)

SOCIAL LANGUAGE SKILLS, Difficulty with;

Social skills
Making and sustaining friendships
Play skills and engagement with others
Communication and anxiety

Any other comments

Include any other comments that will aid in developing a course of treatment for your child.

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 CHILD

Child's first language *

Other languages spoken in the home

Has your child had their hearing tested? *

Yes
No

Has your child ever had Speech Language Therapy? *

Yes
No

Location, services & length of therapy block.

Does your child enjoy or avoid the company of other children? *

Generally enjoys
Generally avoids

Does your child make eye contact with you when speaking or interacting with others? *

Is your child aware of, or frustrated by any speech/language difficulties? *

Please describe your concerns regarding your child's communication *

BIRTH/MEDICAL HISTORY

Does your child have any health concerns you are aware of? *

Yes
No

Has your child had any serious illnesses or injuries? *

Yes
No

Has your child had any of the following?

Please list any medications your child takes regularly

BIRTH/DEVELOPMENT HISTORY

Were there any complications during the pregnancy or birth? *

Yes
No

Please describe the complications experienced during pregnancy or birth

Please provide the approximate age in months your child achieved the following developmental milestones

Sat alone

Babbles

Said first words

Put two words together

Spoke in short sentences

Grasped a crayon or pencil

Walked

Toilet trained

Does your child choke on food or liquids? *

Yes
No

Does your child currently put toys/objects in their mouth? *

Yes
No

Does your child brush their teeth and/or allow you to help them brush? *

Yes
No

SCHOOL HISTORY

Does your child attend school? *

Yes
No

School name and grade they're currently enrolled in

Please provide any additional information you feel may benefit your child's therapy.

Child Case History Form

REASON(S) FOR REFERRAL

SPEECH LANGUAGE HISTORY OF YOUR CHILD

BIRTH/MEDICAL HISTORY

BIRTH/DEVELOPMENT HISTORY

Please provide the approximate age in months your child achieved the following developmental milestones

SCHOOL HISTORY

Thank you for taking the time to fill out our Child Case History Form