Child Case History

Child Name *

Gender *

Date *

Age *

Contact Email Address *

Race *

Child Lives with *

Person Name *

Person Age *

Relationship to child *

Problem *

Is there a language other than English spoken in the home? *

Other Language

Do you feel your child has a speech problem? *

Speech Problem

Do you feel your child has a hearing problem? *

hearing problem

Has he/she ever had a speech screening/evaluation? *

Speech Screening / Evaluation Details and Date

Has your child received any other evaluation or therapy section? *

Other Speech Screening / Evaluation Details and Date

Has he/she ever had a hearing screening/evaluation? *

Hearing Screening Evaluation

Has your child ever had Speech Therapy? *

Speech Therapy - When And Where

What was the Therapist working on? *

Has your child received any other evaluation or therapy? *

Sppech Problem

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

What do you see as your child's most difficult problem in school? *

What do you see as your child's most difficult problem in home ? *

Was there anything unusual about the pregnancy or birth? *

unusual about the pregnancy or birth

Was the mother sick during the pregnancy? *

Problem

Did the child go home with his/her mother from the hospital? *

Child's Hospital Stay

Is your child currently (or recently) under a physician's care? *

physician's care

Medications your child takes

Please tell the approximate age your child achieved the following developmental milestones: - fill in age ex 18 mos

Sat Alone *

Babbled *

Pul two words together *

Walked *

Crawled *

Dressed Self *

Grasped crayon / pencil *

Said first words *

Spoke in short sentences *

Toilet Trained *

Finger Fed Self *

Ate with Utensils *

If your child is in school, please answer the following:

Teacher's Name *

Has your child repeated a grade? *

What are your child's strengths and/or interests/hobbies *

Is your child having difficulty with any subjects? *

Child having difficulty with any subjects

s your child receiving help in any subjects? *

Child receiving help in any subjects

Additional Comments

Child Case History

Please tell the approximate age your child achieved the following developmental milestones: - fill in age ex 18 mos

If your child is in school, please answer the following:

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