Speech Pathology Case History Form

Mother's details

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Please Outline What you are Concerned about with regard to your Child's Speech/Language/Literacy/Social Communication Challenges *

What do you hope to get out of the assessment session? *

What are your child's favourite things to do and to play with? *

Is there anything he/she really dislikes?

Please state when your child said his/her first word *

Is he/she combining words together? *
yesno

At what age did he / she

Is your child able to eat a variety of solid foods with different textures? *
yesno

 

Describe who lives at home with your child

Are there any custody arrangements in place? *

Are you happy for your child to receive speech therapy if the assessment indicates it is needed and would you be willing to be involved in the speech therapy program? *
yesno

Are you happy for Lynne to contact other professionals who have been involved with your child if she feels it would benefit his/her therapy outcome? Please select "yes" or "no" for the following people below: *