Name of person completing form (relationship to client) * Child's name * Gender * 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 referral Does your child have any diagnoses or disorders? * If yes, please describe * Please indicate any major illnesses which the child has had, such as high fevers, measles, tonsillitis, many ear infections, etc. * Does your child have any allergies? * If yes, please describe Has the child been seen by a speech-language pathologist * If yes, when? If yes, name of SLP and facility If yes, findings Has the child been seen by an occupational therapist * 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.) * If yes, please describe Speech and Language History What is your child's most frequently used language? Any other languages? Do you have any concerns with your child’s speech sound production? * Please describe. (e.g. Child produces “snake” as “nake,” or has a frontal lisp, or incorrect R production) Do you have any concerns with your child’s expressive language use? * Please describe. (e.g. Leaves out some words and does not use full sentences, is not using verbs correctly, does not ask or answer questions appropriately) Do you have concerns with your child’s receptive language use? * Please describe. (e.g. Can they follow single step directions (point to your nose), two step or multistep directions (go to the car, get your backpack, and put it on the kitchen table)) 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%)? * What does your child do if they are not understood? * Does your child stutter? (e.g. gets stuck, repeats sounds/words) * If yes, describe Hearing Has your child had ear infections? * If yes, how many and please describe Does the child seem to have any difficulty hearing? * If yes, describe Has your child had a hearing test? * If yes, what were the results and recommendations? Vision Has your child had their vision screened by an optometrist in the past year? * Any concerns? Social/Play History Does your child enjoy or avoid the company of other children? * What are your child’s favourite interests? * Does your child make eye contact with you when speaking or interacting? * Do you have concerns with your child’s social use of language? * Feeding, Swallowing and Oral Structures Is your child a picky eater? (Do they avoid certain textures, types of food, etc.?) If yes, describe * When your child eats, do they frequently have food left on their face? * When your child eats, do they make a lot of noise, or a lot of smacking sounds? * Has your child ever been told they have a tongue tie? * If yes, when? Does your child have any oral habits (e.g. thumb or finger sucking, blanket sucking/chewing, lip or tongue sucking)? Or did they used to? * If yes, please provide duration, frequency and if/when it stopped. Has your child’s dentist or orthodontist mentioned any concerns? * If yes, please describe. Does your child drool or have excessive saliva? * 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, tying shoes, managing utensils at mealtime, using the toilet independently)? Prenatal and Birth History Please describe if there were any any complications during pregnancy or birth Education Does your child currently attend school? * If yes, list school and grade Has your child’s teacher reported any concerns? * If yes, please describe. Is your child currently receiving any supports at school? * If yes, please describe. Additional Comments Please use this space to comment on any other information you feel is important.