Case History Form

What is Speech Language Therapy?

Speech Language Therapy is the treatment of speech and language problems. This can include; stuttering, lisps, pronunciation problems, social language, early reading and literacy skills, language comprehension, expressive language, etc. We do NOT teach English as an additional language.

What is Occupational Therapy?

Occupational Therapy is the treatment of occupational performance issues. These are any areas in one’s life that they are having trouble managing. This can include; self care activities (i.e. toileting, dressing), fine and gross motor skills, play, social skills, cognition (attention, memory, executive functioning), self-regulation, sensory processing, etc.

What is Reading Intervention Therapy?

Structured Literacy is a research-based approach to teaching reading that focuses on the essential components of literacy development in a systematic and cumulative manner. Reading Intervention therapy can be either direct one-on-one or group therapy designed to support children who struggle with reading (for example, they may not know the letter sounds, they may sometimes mix up or reverse letters, read very slowly or have difficulties with spelling.)

What is an Educational Psychology and/or Behaviour assessment?

Psychological/Behaviour Assessments include standardized assessment in the areas of cognitive ability, academic achievement, adaptive functioning and behavior. This information, along with interviews with parents, and clients themselves, is synthesized into a report which clearly outlines strengths and weaknesses, diagnosis if applicable, recommendations for support, and detailed intervention recommendations.

Contact Information - Step 1 of 4

Who is filling out this Case History Form? *

First

Last

I am completing this form for: *

Myself
My Child
Other

Relationship to Client (i.e. Parent, Grandparent, Social or Support Worker, etc.) *

The client is seeking the following services: *

Speech Language Therapy
Occupational Therapy
Structured Literacy Reading Intervention Tutoring
Psychoeducational and Behavioural Assessment Services (Initial Intake, Testing, Reporting and Recommendations only)

Select all that apply

Please select the appropriate age of the client: *

Child (0-17 years of age)
Adult (18+ years of age)

What best describes the client's current status with us: *

Current Client
Previous Client
New Client

Current or previous clients will have the option to update address and contact information

Client's Name *

First

Last

Client's Date of Birth (Month/Day/Year) *

Client's Gender *

Female
Male
Other

Preferred Pronouns *

She/Her
He/Him
Other

Preferred Pronouns (please specify): *

Would you like to update your primary contact information? *

Primary Caregiver's Name *

First

Last

Secondary Caregiver's Name

First

Last

Optional

Primary Contact's Name *

First

Last

Secondary Contact's Name

First

Last

Optional

Primary Email Address *

Secondary Email Address

Optional

Would you like to update your address? *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Would you like to update your phone number(s)? *

Primary Phone *

Secondary Phone

Optional

CLIENT INFORMATION

Client's Marital Status *

Single
Dating
Married
Separated
Divorced
Widowed

Client's Family Relationship *

Nuclear Family (Two parents raising 1+ children in the home)
Single Parent Family (One parent raising 1+ children on their own)
Blended Family (Combination of parents or children from previous relationships)
Grandparent Family (One or more grandparent raising 1+ children in the home)
Extended Family (Several generations of family living in the same home)

Does the client have any children? *

Does the client have siblings? *

Please list the children's names, ages and genders (i.e. Name, Age, Gender) *

Client's first language: *

Other languages spoken in the home:

Optional

EDUCATION

Is the client currently attending school? *

Please indicate the school name and the client's current grade (i.e. School Name, Grade): *

Has the client received services at school? *

Please indicate which services the client may have received at school: *

Speech-Language Pathology
Occupational Therapy
Physical Therapy
Psychoeducational Assessment
Reading Intervention
Other
None of the Above

Please indicate the service(s) provided if not listed above: *

Please indicate the clients highest education completed: *

Please indicate any certificates, diplomas, or degrees attained: *

Names of educational institutes attended: *

Is the client currently employed? *

Is the client currently driving? *

MEDICAL HISTORY

Has the client had any of the following health concerns: *

Adenoidectomy
Allergies
Breathing difficulties
Chicken Pox
CVA (Stroke)
Ear Infections
Ear Tubes
Flu
Encephalitis
Head Injury
High Fevers
Seizures
Meningitis
Sinusitis
Sleeping Difficulties
Tonsillectomy
Tonsillitis
Vision Problems
Serious Illness
Serious Injury
Other
None of the Above

Select all that apply

Please indicate the client's allergies: *

Please indicate any serious illness: *

Please indicate any serious injury: *

Please identify other health concerns not listed above: *

Does the client have any formal diagnosis? (i.e. by a Family Doctor, Specialist, Therapist, etc.)

Speech or Language Delay or Disorder
Autism Spectrum Disorder (ASD)
Global Development Delay (GDD)
Attention-Deficit Hyperactivity Disorder (ADHD)
Attention-Deficit Disorder (ADD)
Other
No Formal Diagnosis

Please list the year that the client received the diagnosis and where the diagnosis occurred (i.e. Year, clinic name, location) *

Has the client been hospitalized in the last 5 years? *

Has the client undergone any surgeries in the past? *

Please indicate the type of surgery and the year it occurred: *

Does the client currently take any medications? *

Please indicate current medications: *

Has the client had their vision tested? *

Has the client had their hearing tested? *

When was the client's hearing tested? *

Where was the client's hearing tested? *

What were the results of the hearing test? *

Does the client wear glasses or hearing aids? *

Glasses
Hearing Aids
Glasses & Hearing Aids
None of the Above

Does the client use adaptive equipment or mobility aids? *

i.e. walker, wheelchair, AFO's, adaptive utensils, etc.

Select the adaptive equipment or mobility aid(s) used by the client: *

AFO (Ankle Foot Orthosis)
Adaptive Utensils
Stair Lift
Scooter
Ramp
Cane
Walker
Wheelchair
Other

Please indicate other adaptive equipment or mobility aids not listed above: *

REFERRAL FOR SERVICES

Who referred the client for services? *

Doctor
Therapist
Teacher
Parent
Relative
Friend
Self
Other

Please choose all that apply.

Please identify who referred the client: *

Has the client been seen by/referred to any of the following specialists (Check all that apply): *

Speech-Language Pathologist
Occupational Therapist
Social Worker
Psychologist
Counsellor
Audiologist
Psychiatrist
Physical Therapist
Otolaryngologist
Neurologist
Gastroenterologist
Ear Nose and Throat Specialist (ENT)
NONE OF THE ABOVE

Please indicate the reason for visit/referral to the above specialist(s): *

Physician and/or other Healthcare Professional(s) who have seen the client (Please include the year seen):

Doctor, Speech-Language Pathologist, Occupational Therapist, Physical Therapist, Dentist, Orthodontist, Registered Nurse, etc.

Has the client had previous Speech Language Therapy before? *

Yes, through Health Services (i.e. Alvin Buckwold Child Development Programs, Jim Pattison Children's Hospital or another hospital, health clinic, etc.)
Yes, through the School System (i.e. preschool, elementary or high school)
Yes, with a Private Therapist or Clinic
No

Please tell us how long, when and who provided the previous Speech Therapy: *

Do you have any documentation from the previous Speech Language Therapy? (i.e. reports, assessments, etc.) *

Has the client had previous Occupational Therapy before? *

Yes, through Health Services (i.e. Alvin Buckwold Child Development Program, Jim Pattison Children’s Hospital or another hospital, health clinic, etc.)
Yes, through the School System (ie. preschool, elementary or high school)
Yes, with a Private Therapist or Clinic
No

Please tell us how long, when and who provided the previous Occupational Therapy: *

Do you have any documentation from the previous Occupational Therapy? (i.e. reports, assessments, etc.) *

Has the client had previous Reading Intervention and/or Tutoring before? *

Yes, through the School System (ie. preschool, elementary or high school)
Yes, with a Private Tutor
No

Please tell us how long, when and who provided the previous Reading Intervention: *

Do you have any documentation from the previous Reading Educator/Tutor? (i.e. reports, assessments, etc.) *

Has the client accessed a Psycologist or Psychoeducational Assessment before? *

Yes, through Health Services (i.e. Alvin Buckwold Child Development Program, Jim Pattison Children’s Hospital or another hospital, health clinic, etc.)
Yes, through the School System (ie. preschool, elementary or high school)
Yes, with a Private Psychologist or Clinic
No

Please tell us how long, when and who provided the previous Psychoeducational Assessment or Psychologist Services: *

Do you have any documentation from the previous Psychologist/Psychoeducational Assessment? (i.e. reports, assessments, etc.) *

SPEECH / VOICE - Difficulties with:

Speech sounds / enunciation
Tongue Thrust (referred by a Dentist/Orthodontist)
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

Primary Occupational Therapy Concerns (Check all that apply): *

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
Other

Are the client's speech difficulties experienced in all spoken languages? *

In which language are the client's speech difficulties? *

Is the client currently 5 years of age or younger? *

Approximately how many words does the client use? *

How well do YOU understand the child (Around what percentage of their language do you understand)?

I rarely understand (0% - 25%)
I sometimes understand (25% - 50%)
I often understand (50% - 75%)
I always understand (75% - 100%)

How well do OTHERS understand the child (Around what percentage of their language do they understand)?

They rarely understand (0% - 25%)
They sometimes understand (25% - 50%)
They often understand (50% - 75%)
They always understand (75% - 100%)

Does the client enjoy or avoid the company of other children? *

Generally enjoys
Generally avoids

Does the client make eye contact with you when speaking or interacting with others? *

Yes, always
Frequently
Sometimes
Rarely
No

Is the client aware of, or frustrated by, any speech/language difficulties? Please describe: *

Please describe any concerns regarding the client's communication: *

How would you rate your child's listening ability when given simple instructions either at home or at school?

Always, or almost always, listens when spoken to directly
Usually listens when spoken to directly (age appropriate)
Often does not seem to listen when spoken to directly
I don't know

When you child gets upset to they act aggressively towards other people, themselves or property? (i.e. do they hit, kick, bite, pinch, scratch, push, throw objects, threaten or break/destroy things?

If yes, please breifly describe this behaviour, what typically causes the behaviour and how frequently does this behaviour occur: *

Is your child uncooperative? (i.e. do they frequently refuse to follow instructions or rules, act defiantly, argue or talk back to adults, pout, refuse to take turns oor share with other children, etc.)

If yes, please briefly describe this behaviour, what typically causes the behaviour and how frequently does this behaviour occur: *

What are the client's strengths? *

What are the client's interests? *

What are your concerns regarding the client's reading skills? *

How does the client feel about reading?

What struggles does the cient experince with reading? (ie. in your opinion and/or from what the school/teacher has brought to your attention, etc.)

Have their struggles with reading affected their confidence? If so, how?

What instructional and/or assessment program does the client's school use?

Does the client have sustained attention? (ie. is the client able to sit at a table for a length of time, do they struggle with sitting skill, etc.)

Does the client experience dysregulation either while reading or trying to read?

How would you rate the client's listening ability when given simple instructions either at home or at school?

Please identify why the client is interested in/referred for Psychological services: *

Psychoeducational Assessment
Behavioural Assessment
Review/Update Recommendations
Other

Please indicate why if you selected other: *

Please provide any additional information regarding the client's interest in Pyschological services:

INDEPENDENCE & SUPPORT SYSTEM

Please identify the client's support system (check all that apply): *

Co-workers
Grandparent(s)
Parent(s)
Sibling(s)
Friend(s)
Teacher
Educational Assistant (EA)
Social Worker
Other
None of the Above

Please indicate other members of the client's support system not listed above: *

Please indicate the client's level of independence on a daily basis: *

Completely independent
Rarely requires assistance
Sometimes requires assistance
Frequently requires assistance
Requires total assistance

SUBSTANCE USE/EXPOSURE

Has the client ever used or been exposed to any of the following substances (Check all that apply): *

Alcohol
Marijuana (i.e. smoke/edibles)
Tobacco
Illicit Drugs
Other
None of the Above

Please indicate any substances the client used or was exposed to that are not listed above: *

BIRTH/DEVELOPMENT HISTORY

Did the client experience any complications throughout the pregnancy or birth? *

i.e. drug use throughout pregnancy, surgery, intensive care, etc.

Please describe the complications the client experienced during pregnancy or birth. *

Developmental Milestones

Please provide the approximate age in months the client achieved the following developmental milestones:

Sat alone (unassisted) *

Babbles *

Said first words *

Put two words together *

Spoke in short sentences *

Grasped a crayon or pencil *

Walked *

Toilet trained *

Does the child do the following (check all that apply): *

Drink from an open cup
Use a spoon and/or fork
Choke on foods and/or liquids
Play with a variety of toys
Place toys/objects in their mouth
Brush their teeth/allow someone to help brush their teeth
Dress themselves
Undress themselves
None of the Above

Thank you for completing our case history form

What would your preferred day or time for therapy be? *

When booking appointments we will try our best to accommodate you, however, please be aware that your preferred times and dates may not be available.

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?

Please provide us with the persons name if possible so we can thank them!

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