Child Case History Form

The following information is for professional use and will be handled confidentially. This information will assist the speech language pathologist in completing your child’s evaluation.

Please complete the following questions as fully and accurately as possible. If you are unable to complete a question, please leave it blank or you may call our office for assistance at (678) 705-1221.

Name of Person completing this form:*
E-mail:*
Relationship to this Child:*
Child's Name:*
Nickname(s):
Date of Birth:*
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Age:*
Sex:*

Sibling Information

Sibling #1 Name:
Sibling #1 Age:
Sibling #1 Sex:
Sibling #2 Name:
Sibling #2 Age:
Sibling #2 Sex:
Sibling #3 Name:
Sibling #3 Age:
Sibling #3 Sex:
Primary Language:*
What Language Does The Child Speak?:*
Please indicate your primary concern about your child’s speech and language skills:*

Medical History

Please indicate if the child has experienced any of the following conditions:

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Child’s Primary Care Physician:*
Has your child had an audiological evaluation (hearing test)?:>*
When?:*
Where?:*
Were the results normal?:*
If no, please explain:
Occurrence of ear infections?:*
If “yes”, approximately how many ear infections to date?:
Has your child had any speech and language testing?:*
If, “yes”, Where did this take place?:
Has your child had any Speech and Language Intervention?:*
If "yes", where did the intervention take place?:
List any medications prescribed for your child:
If your child has had other significant medical treatment, please explain:

Developmental History

Prenatal and Birth History

Length of pregnancy:*
Delivery Complications:*
Please explain if any complications occurred:
Birth weight:*
Did the infant have any difficulty with breathing, crying, sucking, jaundice, convulsions, blood incompatibility, etc.? (Please explain):

A. Motor Milestones

Please indicate the age or approximate age at which the following occurred:

Crawled:
Sat alone:
Walked unaided:
Fed self:
Dressed self:
Toilet trained:
Cooing:
Babbling:
First words:

Vocabulary of approximately 50 words:

# Understood:
# Expressed:
# Two-word combinations (examples: more milk, me do, no go):
# Short Sentences (examples: Me want juice., Mommy do it.):

B. Receptive and Expressive Language Skills

Please answer “yes” or “no” or “sometimes” to the following questions:

Does your child respond to his/her name?*
Will your child get common objects when asked?*
Does your child follow simple directions?*
Will your child point to pictures as you name them?*
Does your child label pictures?*
Does your child ask questions?*
Please give examples:
Does your child repeat or “echo” others’ expressions?*
Does your child repeat questions or parts of questions rather than answering them?*
Does your child excessively recite/repeat words from video tapes/DVDs, songs, or television programs?*
Has your child said a word and few times, then never used it again?*
If “yes”, when & what words?:
Did language development seem to just stop?*
If “yes”, when?
How does your child indicate his/her needs/wants to you?:*
How does your child indicate he/she does not want something or does not want to do something?:*
What types of words/sentences does your child express independently?:*

Behavioral Information

A. Infancy

Was a silent infant?*
Was an inconsolable infant?*
Very happy infant (rarely cried, did not desire interaction/affection)?*
Other comments about Infancy:

B. Play

Prefers to play alone?*
Plays poorly with other children or does not interact with others?*
Frequently lines items in a row?:*
Protests if line is interrupted?:*
Holds (clutches) items for extended periods of time?:*
Frequently counts (objects, items, actions etc):*
Has unusual interest (strips of paper, electrical cords etc.)?:*
Spins objects?:*
Other comments about Play:

C. Conduct

Is difficult to manage?*
Has a behavior problem?*
Displays temper tantrums?*
Consistently has a catastrophic reaction when told “no”?*
Discipline is ineffective?*
Is overly active?*
Has a short attention span?*
Is aggressive towards self?*
Is aggressive towards others?*
Is destructive with objects?*
Other comments about Conduct:

D. General

Is withdrawn?*
Rocks back and forth?*
Acts as if deaf?*
Covers ears with hands?*
Has limited eye contact?*
Has difficulty with change/transitions?*
Other comments about General Behaviors:

Education Information

Is your child currently enrolled in school?*
If yes, school name and days attended:
If yes, what grade/classroom level:

Supportive Services

Please enclose a copy of the child’s most recent IEP or IFSP and Therapy goals from each area that is checked:

Upload File Here:

Service/Therapy

What other services is your child currently receiving both in-school and out of school?

Early Intervention Services:
a. Minutes/Week:
Speech and/or language therapy:
b. Minutes/Week:
Occupational and/or Physical Therapy:
c. Minutes/Week:
Vision services in school:
d. Minutes/Week:
Hearing services:
e. Minutes/Week:
Other:
f. Minutes/Week:

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Please describe your child’s personality:*

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Please feel free to indicate any questions or concerns that you would like to specifically discuss at your initial appointment:*

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How did you hear about Communicate to Connect Therapy, LLC?*

By typing your full name/initials and date, you are signing this consent form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this consent form. You also represent that you are authorized to provide consent for the client whom this document is in regards to.

Electronic Signature:*
Today's Date:*
Time:*
 : 
Word Verification:

Thank you for taking the time to complete this form.

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