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Speech Pathology Case History Form

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Note: Field marked with an asterisk are required fields


Mother's details


Father's details

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

sit *
crawl *
walk *
Is he/she toilet trained? *
yesno
If so at what age was he/she dry during the day at night?
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? *

Has anyone in the family had a speech/language or learning difficulty? *
yesno
If so, please describe the type of difficulty and whether they received speech therapy.
Has your child had a recent hearing test? *
yesno
If so, when?
What were the results?
Has your child seen another speech pathologist? *
yesno
If so, who and when?
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: *

Your Child's Doctor *
Your Child's Health Nurse *
Your Child's Day Care Provider *
Your Child's Teacher *
The School Psychologist *
Grandparents *
yesno
By clicking here you are happy to forward these details *
Today's Date *