Relationship to child
Referred by eg. parent/school/doctor *
Child's name *
Primary address *
Parent/guardian name(s) *
Primary phone *
Alternate phone
Email *
Please list other children in family (including age)
Reason for referral *
If yes, date
Name of SLP and facility
If yes, findings
If yes, date
Name of OT and facility
If yes, findings
If yes, please describe
What is your child's first Language? *
Second language?
When did your child say his/her first words? *
When did your child combine words to form sentences? *
How does your child typically communicate (eg. with gestures or words)? *
Give an example of something your child communicated today (either with words or gestures) *
If with words, how many words does your child typically put together to form a sentence?
If yes, provide examples
What does your child do if she/he is not understood? *
If yes, describe
If yes, how many?
If yes, what were the results and recommendations?
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? *
At what age did your child sit independently? *
At what age did your child crawl? *
At what age did your child walk? *
At what age did your child finger feed? *
At what age did your child toilet train? *
If yes, describe
Is your child able to feed themselves? (finger feed, hold a spoon, drink through a cup or straw)
If yes, describe (copy)
If yes, describe
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. *
If yes, please describe
If yes, list school and grade
If yes, please describe
Please use this space to comment on any other information you feel is important
