Child Case History

Child Name *

Gender *GenderMaleFemaleOther

Date *

Age *

Contact Email Address *

Race *RaceCaucasian / WhiteAfrican American / BlackHispanicAsianOther

Child Lives with *Child Lives withBirth ParentsMotherFatherAdoptive ParentsFoster ParentsGrandparent(s)

Person Name *

Person Age *

Relationship to child *

Problem *

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

Other Language

Do you feel your child has a speech problem? *Do you feel your child has a speech problem?YesNo

Speech Problem

Do you feel your child has a hearing problem? *Do you feel your child has a hearing problem?YesNo

hearing problem

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

Speech Screening / Evaluation Details and Date

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

Other Speech Screening / Evaluation Details and Date

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

Hearing Screening Evaluation

Has your child ever had Speech Therapy? *Has your child ever had Speech Therapy?YesNo

Speech Therapy - When And Where

What was the Therapist working on? *

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

Sppech Problem

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

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? *Was there anything unusual about the pregnancy or birth?YesNo

unusual about the pregnancy or birth

Was the mother sick during the pregnancy? *Was the mother sick during the pregnancy?YesNo

Problem

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

Child's Hospital Stay

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

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? *Has your child repeated a grade?YesNo

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

Is your child having difficulty with any subjects? *Is your child having difficulty with any subjects?YesNo

Child having difficulty with any subjects

s your child receiving help in any subjects? *s your child receiving help in any subjects?YesNo

Child receiving help in any subjects

Additional Comments

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