Speech and Language Case History Information
Personal Information
Child's Name
*
First Name
Last Name
Daycare/School Name
*
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Phone Number
*
-
Area Code
Phone Number
Child's Birth Date
*
January
February
March
April
May
June
July
August
September
October
November
December
Month
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Gender
*
Male
Female
Parent E-mail
Marital Status
Single
Married
Divorced
Separated
Widow(er)
Spouse's Name
Spouse's Email
Spouse's Number
Number of Children
Children's Names, Ages
Emergency Contact
*
Emergency Contact Phone Number
*
Primary Care Physician
Primary Care Physician's Phone Number
How were you referred to our office?
*
Child's race/ethnic group
*
Any other language(s) besides English spoken in the home? If yes, which one(s):
*
What language does the child prefer to speak?
Does your child understand the language?
Back
Next
Financial Information
How I plan to pay for therapy:
*
I plan to use my insurance.
I want to pay for my therapy.
Committee on Preschool Special Education
Committee on Special Education
Please explain my options
It is important that you call your insurance carrier to find out any information you may not know. If your insurance does not pay for services rendered, you are financially responsible
Primary Insured's Name
*
Primary Insured's Date of Birth
*
Primary Insured's Social Security Number
*
Insurance Company
*
Insurance Contact Number
*
Member ID
*
Specialist Co-payment
*
Individual Deductible amount
*
Deductible met?
*
Referral needed for speech? Y/N
*
Insurance Card
Please upload the front of your insurance card here:
Please upload the back of your insurance card here:
Number of authorized sessions
*
Authorization Number
*
You are aware that if your insurance company does not pay, you are financially responsible for any services rendered. Please type your name in the box to the right indicating that you are aware that you will be responsible should your insurance plan not pay. We will charge your insurance as a courtesy, but ultimately, you are responsible.
*
Back
Next
Speech-Language-Hearing
Do you feel your child has a speech and/or language problem?
If yes, Please explain:
Has your child had a speech and or language evaluation in the past?
*
Yes
No
If so, when?
Where was the evaluation performed?
Please upload a copy of the most recent evaluation report:
What were the results of the evaluation? What were you told?
Has your child ever had speech therapy?
If yes, when and where?:
Is your child aware of or frustrated by any speech/language difficulties? If yes, explain:
What do you see as your child's most difficult problem in the home?
How does your child communicate? Check all that apply:
Body language
Sounds (vowels, grunting)
Words (shoe,doggy,up)
2 to 4 word sentences
Sentences longer than 4 words
Other
Did your child ever have a hearing screening/evaluation?
*
If yes, when and where?
Please upload a copy of the latest report:
Has your child received any other evaluation or therapy (physical therapy, counseling, occupational therapy, vision therapy, etc.)?
*
Back
Next
Birth History
Was there anything unusual about the pregnancy or birth?
Child's weight at birth
How was child delivered? (C-section or vaginal)
Was mother sick during pregnancy? If yes, describe:
Did the child go home with the mother from the hospital? If no, describe why child stayed and how long:
Medical History
Has your child had any of the following?
Adenoidectomy
Allergies
Breathing difficulties
Chicken pox
Ear infections
Ear tubes
Encephalitis
Flu
Head injury
High fevers
Measles
Meningitis
Mumps
Scarlet fever
Seizures
Sinusitis
Sleeping difficulties
Thumb/finger sucking habit
Tonsillectomy
Tonsillitis
Vision problems
List any major illnesses or hospitalizations:
What medications or drugs does your child take and how often?
List any other health problems, no matter how insignificant they may be:
Back
Next
Developmental History & Behavioral Characteristics
age child babbled
age child talked
age child sat alone
age child crawled
age child walked
Does your child do any of the following (Please check all that apply)
Choke on food or liquids?
Currently put toys/objects in his/her mouth?
Suck his/her thumb
Brush his/her teeth and/or allow brushing?
Use a pacifier
Take vitamin supplements
Does your child do any of the following? (Please check all that apply)
Repeat sounds, words or phrases over and over?
Understand what you are saying?
Retrieve/point to common objects upon request (ball, cup, shoe)?
Follow simple directions ("go get the cup")
Respond correctly to yes/no questions?
Respond correctly to who/what/when/where/why questions?
Behavioral characteristics. (Please check all that apply)
Cooperative
Attentive
Willing to try new activities
Plays alone for reasonable length of time
Separation difficulties
Easily frustrated/impulsive
Stubborn
Restless
Poor eye contact
Easily distracted/short attention
Destructive/aggressive
Withdrawn
Inappropriate behavior
Self-abusive behavior
Back
Next
School History-If you child is in school, please answer the following:
Name of School and grade:
What are your child's strengths and/or best subjects
Teacher's name:
Is your child having difficulty with any subjects? If so, please explain:
Does your child have any interest in books? Describe:
Describe your child's current literacy/writing status. Does he/she recognize letters, sounds they make,trace, read?
Back
Next
Family History
Does anyone in your family have a history of speech/language delays or learning disabilities? If so, please explain:
Back
Next
Signature and Submission
Please type your name below to indicate consent to treatment.
Parent/Guardian Signature
Date
January
February
March
April
May
June
July
August
September
October
November
December
Month
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Enter the message as it's shown
*
If you have any additional concerns or questions not addressed:
If you have any additional concerns or questions not addressed:
If you have any additional reports that may help with the evaluation process, please upload them here:
Click to edit
*
Click to edit
Click to edit
Submit
Should be Empty: