Case History Form (CHILD)
Now We're Talking Speech Pathology & Psychology

1. General Information

We ask that you take 10-15 minutes to complete this form with as much detail as possible. This will help the Speech Pathologist when the time comes to start therapy.

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* 1. Client's Name

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* 2. Date of Birth

Date / Time

Date

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* 3. Parent/ Guardian 1 (Primary Carer)

Name

Contact Phone Number

Email Address

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* 4. Parent/ Guardian 2

Name

Contact Phone Number

Email Address

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* 5. Home Address

Street Number and Name

Suburb

Postcode

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* 6. Please list all family members that live at home? If siblings, please include names and ages

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* 7. What is the Primary Language Spoken at home? Any other Languages spoken at home?

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* 8. Support Networks outside of the home- Does anyone else provide care for the client?

Grandparent

Other relative (Aunt, Cousin)

Friend

Classroom Aide

Support worker

Respite

None of the above

Other (please list details of all applicable)

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* 9. Client's Current Kinder/ School/ Daycare

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* 10. Year Level at School and Teacher's Name (if applicable)

Year Level

Teacher's Name

Teacher's Contact details

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* 11. How is the client progressing academically? Has the teacher raised any concerns with any part of the clients development?

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* 12. What areas do you feel the client needs assistance with? Tick all that may be applicable

Articulation (eg. how the client pronounces sounds/ words/ lisp)

Emotional Regulation (eg. frequent tantrums or meltdowns, inability to self regulate big emotions leading to traits like anger, withdrawal, anxiety or aggression)

Expressive Language (talking) (eg. reduced verbal output, incorrect grammar)

Fluency (stuttering)

Language delay - for ages 2-5 yrs (eg. not speaking or reduced list of words)

Literacy/ Learning difficulties (eg. reading, writing)

Receptive Language (listening) (eg. difficulty following instructions, 'not listening')

Situational Non Speaking (eg. selective mutism)

Social Skills (eg. greetings, friendships. conversational skills)

Swallowing (eg. coughing when drinking, choking or food getting 'stuck')

Tutoring

Voice (eg. tone/ pitch/ volume/ harshness, husky/ Losing voice)

Other (please specify)

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* 13. When did you first notice any of the above concerns? Has the difficulty changed since it was first noticed? Please provide as much information as possible

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* 14. Does the client have a formal diagnosis?

Autism Spectrum Disorder (ASD)

ADHD

Specific Language Disorder (SLD)

Global Developmental Delay (GDD)

Dyslexia

Intellectual Disability

Auditory Processing Disorder (APD)

Developmental Language Disorder (DLD)

Apraxia of Speech

Articulation Disorder

Phonological Disorder

Hearing Impairment

None of the above

Other (please specify)

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* 15. Is the client aware of their challenges? If the child has a formal diagnosis, are they aware of their diagnosis?

Yes (if yes, please provide comment on how they feel about it)

Comment

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* 16. Has the client seen a Speech Pathologist previously?

Yes- Please provide details in comments below

When did they see Speech Pathologist? What were the conclusions or suggestion's made?

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* 17. Have any other specialists assessed or treated the client? (please select all applicable)

Occupational Therapist (OT)

Psychologist

Paediatrician

Behavioural Therapist

ENT

Physiotherapist

None of the above

Other (please specify)

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* 18. Please detail any specialists that have previously treated the client or are currently engaged with the client- including type of specialist, name and contact details, when they were seen and the conclusions and suggestions.

Not Applicable

Specialist 1

Specialist 2

Specialist 3

Specialist 4

Specialist 5

Case History Form (CHILD)Now We're Talking Speech Pathology & Psychology

1. General Information

Question Title

* 1. Client's Name

Question Title

* 2. Date of Birth

Question Title

* 3. Parent/ Guardian 1 (Primary Carer)

Question Title

* 4. Parent/ Guardian 2

Question Title

* 5. Home Address

Question Title

* 6. Please list all family members that live at home? If siblings, please include names and ages

Question Title

* 7. What is the Primary Language Spoken at home? Any other Languages spoken at home?

Question Title

* 8. Support Networks outside of the home- Does anyone else provide care for the client?

Question Title

* 9. Client's Current Kinder/ School/ Daycare

Question Title

* 10. Year Level at School and Teacher's Name (if applicable)

Question Title

* 11. How is the client progressing academically? Has the teacher raised any concerns with any part of the clients development?

Question Title

* 12. What areas do you feel the client needs assistance with? Tick all that may be applicable

Question Title

* 13. When did you first notice any of the above concerns? Has the difficulty changed since it was first noticed? Please provide as much information as possible

Question Title

* 14. Does the client have a formal diagnosis?

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* 15. Is the client aware of their challenges? If the child has a formal diagnosis, are they aware of their diagnosis?

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* 16. Has the client seen a Speech Pathologist previously?

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* 17. Have any other specialists assessed or treated the client? (please select all applicable)

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* 18. Please detail any specialists that have previously treated the client or are currently engaged with the client- including type of specialist, name and contact details, when they were seen and the conclusions and suggestions.

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* 19. Please list the client's STRENGTHS

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* 20. Please list the client's special interests and things that they enjoy doing

Case History Form (CHILD)
Now We're Talking Speech Pathology & Psychology