Name of person completing form (relationship to client):
Referred by eg. parent/doctor: Child's name:
Gender:
Male Female
Date of Birth: Age: Primary Address: Parent/Guardian Name(s): Primary Phone: Alternate Phone: Email: Alternate Address: Please list other children in family (including age): Reason for referral: Has the child been seen by a Speech-Language Pathologist: Yes No If yes, date: Name of SLP and facility: If yes, findings:
Has the child been seen by an Occupational Therapist: Yes No If yes, date: Name of OT and facility: If yes, findings:
Has the child been seen by other professionals?: Yes No If yes, please describe:
Speech and Language History
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
If with words, how many words does your child typically put together to form a sentence?:
Does your child understand:
a) Single directions (e.g. point to your nose): Yes No
b) 2 step directions (e.g. get your shoes and give them to me): Yes No
c) Simple questions (e.g. where’s your teddy?): Yes No
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 she/he is 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? (If yes, how many?):
Does the child seem to have any difficulty hearing?: Yes No
Has your child had a hearing test?: Yes No
If yes, what were the results and recommendations?:
Social/Play History
Does your child enjoy or avoid the company of other children?:
What are your child’s favorite interests?:
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? : 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?:
Education
Does your child currently attend school?: Yes No
If yes, list school and grade:
Please use this space to comment on any other information you feel is important.
