What best describes your child's current status with us: *

Current Client
Returning Client
New Client
Unsure

Current or returning clients will not be required to provide detailed contact & address information

Child's First Name *

Child's Last Name *

Child's Date of Birth *//

Child's Gender *

Male
Female
Gender X

I'm seeking the following services for my child: *

Speech Language Therapy
Occupational Therapy

Check 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 Name

Optional

Parent/Guardian 2 email address

Optional

As a Returning Client, would you like to update your address?

As a Current Client, would you like to update your address?

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

As a Returning Client, would you like to update your phone number(s)?

As a Current Client, would you like to update your phone number(s)?

Primary Phone *

Secondary Phone

Does your child have siblings? *

Please 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? *

Doctor
Parent
Relative
Therapist
Teacher
Friend
Self
Other

Please choose all that apply.

REASON(S) FOR REFERRAL

Check all that apply

SPEECH / VOICE, Difficulties with:

Speech sounds / enunciation
Tongue Thrust
Lisp
Stuttering
General Voice (nodules, hoarse, overuse)

LANGUAGE / COMMUNICATION, Difficulties with:

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

SOCIAL LANGUAGE SKILLS, Difficulties with:

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

Occupational 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 CHILD

Child's first language *

Other languages spoken in the home

Has your child had their hearing tested? *

Has your child ever had Speech Language Therapy? *

Location & year(s) Speech Language Therapy was provided: *

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? *

Yes, always
Frequently
Sometimes
Rarely
No

Is 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? *

Yes
No
Unsure

Where has your Child had Occupational Therapy before? *

Please describe the Occupational Therapy services your child received: *

BIRTH/MEDICAL HISTORY

Has your child had any surgeries *

Yes
No
Unsure

Please indicate any surgeries your child has undergone in the past: *

Does your child use any equipment? *

Such 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? *

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

Has your child had any serious illnesses or injuries? *

Has your child had any of the following? *

Adenoidectomy
Allergies
Breathing difficulties
Ear infections
Ear tubes
Flu
Encephalitis
Head injury
High fevers
Seizures
Meningitis
Sinusitis
Sleeping difficulties
Tonsillectomy
Tonsillitis
Vision problems
Chicken Pox
N/A

Please list any medications your child takes regularly

BIRTH/DEVELOPMENT HISTORY

Were there any complications during the pregnancy or birth?

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 drink from an open cup? *

Does your child use a spoon and/or fork? *

Does your child choke on food or liquids? *

Does your child play with a variety of toys? *

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

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

Does your child dress themselves? *

Does your child undress themselves? *

Check all that apply to your child: *

Difficulty calming when upset
Frequent tantrums
Poor attention span
Fussy eater
Difficulties with transitions
Difficulties with following family routines
Mouths objects
Seems to be ‘on the go’ (fidgets, wiggles, difficulty sitting still)
Seeks movement (spins, rocks, jumps more than others)
Dislikes hair washing
Avoids messy play or certain textures with their hands
Enjoys messy play
Sensitive to noises (e.g. cries, runs, covers ears)
Avoids wearing certain textures of clothing
Appears clumsy
Dislikes playground equipment
N/A

SCHOOL HISTORY

Does your child attend school? *

School name and grade they're currently enrolled in *

Please indicate which therapy services your child may have received at school:

Speech-Language Therapy
Occupational Therapy
Physical Therapy
Unsure

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

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

How did you hear about us? *

Family or Friends
Co-worker
Facebook
Twitter
LinkedIn
Instagram
News article
Radio/TV
Web search results
Other

Please choose all that may have contributed to you choosing us.

Who can we thank for your referral?

Phone