Name of person completing form (relationship to client):

Referred by eg. parent/school/doctor:
Child's name:

• Gender:
  MaleFemale

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: YesNo
If yes, date:
Name of SLP and facility:
If yes, findings:

Has the child been seen by an Occupational Therapist: YesNo
If yes, date:
Name of OT and facility:
If yes, findings:

Has the child been seen by other professionals?: YesNo
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
gestures:

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): YesNo

b) 2 step directions (e.g. get your shoes and give them to me): YesNo

c) Simple questions (e.g. where’s your teddy?): YesNo

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?: YesNo

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): YesNo

If yes, describe:

Hearing

Has your child had ear infections? (If yes, how many?):

Does the child seem to have any difficulty hearing?: YesNo

Has your child had a hearing test?: YesNo

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? : YesNo

If yes, please describe:

At what age did your child crawl?:

At what age did your child walk?:

Does your child drool?: YesNo

Do you have any concerns about your child’s eating?:

Education

Does your child currently attend school?: YesNo

If yes, list school and grade:

Please use this space to comment on any other information you feel is important.

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