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Client Background Information: Child Age 0 – 5
Scott
2022-11-08T11:02:04-07:00
Client Background Information: Child Age 0 – 5
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Name of person completing form (relationship to client)
*
Child's name
*
Gender
*
Date of Birth
*
Age
*
Primary Address
*
Parent/Guardian Name(s)
*
Primary Phone
*
Alternate Phone
*
Email
*
Alternate Email Address
*
Please list other children in family (including age)
*
Referred by (e.g. parent/school/doctor)
Reason for completing this form
*
Speech services
OT services
Other
If other, please describe
Does your child have any diagnoses or disorders?
*
Yes
No
If yes, please describe
*
Has the child been seen by a speech-language pathologist?
*
Yes
No
If yes, when?
If yes, name of SLP and facility
If yes, findings
Has the child been seen by an occupational therapist
*
Yes
No
If yes, when?
Name of OT and facility
If yes, findings
Has the child been seen by other professionals (e.g. psychologist, developmental pediatrician, etc.)
*
Yes
No
If yes, please describe
Speech and Language History
What is your child's first language?:
*
Any other languages?
When did your child say their first words?
*
When did your child combine words to form sentences?
*
How does your child typically communicate (eg. with gestures or words)?
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Give an example of something your child communicated today (either with words or gestures)
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If with words, how many words does your child typically put together to form a sentence?
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Does your child understand
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Single directions (e.g. point to your nose)?
2 step directions (e.g. get your shoes and give them to me)?
Simple questions (e.g. where’s your teddy?)
How well do you understand your child (from 0% to 100%)?
*
How well do you other family members understand your child (from 0% to 100%)?:
*
How well do you other strangers understand your child (from 0% to 100%)?
*
Are there certain sounds that your child has difficulty pronouncing?
*
Yes
No
If yes, provide examples
What does your child do if they are not understood?
*
Does your child stutter? (e.g. gets stuck, repeats sounds/words)
*
Yes
No
If yes, describe
Hearing
Has your child had ear infections?
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Yes
No
If yes, how many?
Does the child seem to have any difficulty hearing?
*
Yes
No
If yes, describe
Has your child had a hearing test?
*
Yes
No
If yes, what were the results and recommendations?
Vision
Has your child had their vision screened by an optometrist in the past year?
*
Yes
No
Any concerns?
Social/Play History
Does your child enjoy or avoid the company of other children?
*
What are your child’s favourite interests?
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Does your child make eye contact with you when speaking or interacting?
*
Prenatal and Birth History
Please describe any complications during pregnancy or birth
*
Please indicate any illnesses which the child has had, such as high fevers, measles, tonsillitis, earaches, etc.
*
Does your child have any allergies?
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Yes
No
If yes, please describe
At what age did your child crawl?
At what age did your child walk?
Does your child drool?
*
Yes
No
Do you have any concerns about your child’s eating?
*
Yes
No
If yes, please describe.
Self Help Skills
Do you have any concerns with your child’s ability to complete self help skills that you would expect for their age (e.g. putting on their clothing, managing utensils at mealtime, using the toilet independently)?
*
Yes
No
If yes, please describe
Education
Does your child currently attend school?
*
Yes
No
If yes, list school and grade
Has your child’s teacher reported any concerns?
*
Yes
No
If yes, please describe.
Is your child currently receiving any supports at school?
*
Yes
No
If yes, please describe.
Additional Comments
Please use this space to comment on any other information you feel is important.
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