Case History Form

Child's Name

First NameLast Name

Child's Birth Date

DayMonthYear

Child's Gender

Parent/Guardian's Name

First NameLast Name

Relationship to Child

Parent/Guardian's Age

Parent/Guardian's Occupation

Parent/Guardian's Email

Address

Street Address

Street Address Line 2

SuburbState

Postcode

Contact Number

Additional Contact Number

Second Parent/Guardian's Name

First NameLast Name

Relationship to Child

Second Parent/Guardian's Age

Second Parent/Guardian's Occupation

Second Parent/Guardian's Email

example@example.com

Address (if different to above)

Street Address

Street Address Line 2

SuburbState

Postcode

Contact Number

Other Children in the Family

NameAge

Are there any court orders in place relating to custody of your child?

Please select

Does your child receive government funding?

Plan management agency:

Please describe any family history of speech or language problems:

Please list any languages other than English spoken at home:

Does your child speak the language?

Please select

Does your child understand the language?

Please select

Address of Childcare/Kindergarten/School

Name of Institution

Street Address

SuburbPostcode

Contact Number

Teacher or Contact Person

Grade/Level

Is your child receiving funding and/or additional help, e.g. do they have an aide? If yes, please provide details:

Has your child skipped or repeated any grades? If yes, please provide details:

Does your child have any allergies? If yes, please provide details:

Did you or your child experience any health issues during your pregnancy or injuries during the birth or in the days following birth? If yes, please provide details:

Please write the approximate age your child achieved the following developmental milestones:

Babbled

Said first word

Walked

Spoke in short sentences

Is there another developmental milestone or skill that you feel that your child has not/did not achieve at the appropriate age? If yes, please provide details:

Does your child have a diagnosis of a medical condition or developmental delay? If yes, please specify:

If your child has a diagnosis of Autism Spectrum Disorder (ASD), please advise which level:

Other

Has your child ever seen any of the following professionals?

Please describe the purpose of the visit(s) noted above, including dates seen:

Please tick any of the following that your child has experienced:

Please provide details:

Does your child take any regular medication? If yes, please specify:

Does your child require glasses? If yes, please specify for what tasks:

Please provide date and results of your child's last hearing test:

(PLEASE NOTE- We STRONGLY suggest having your child's hearing tested if it has not been checked in the past 12 months)

Do you feel that your child has difficulties with understanding language (e.g. following instructions or stories, understanding words or concepts)?

Do you feel that your child has difficulties with producing language (e.g. vocabulary, describing things, telling a story about past events)?

Do you feel that your child has difficulties with producing speech sounds (e.g. lisp, can't say some sounds, has difficulty with pronunciation of words)?

Do you feel that your child has difficulties with hearing (e.g. not responding to their name, appears to have “selective hearing”, doesn't respond to questions or instructions)?

Do you feel that your child has difficulties with literacy skills (e.g. struggles with spelling, writing, reading, letter names/sounds)?

Do you feel that your child shows signs of stuttering (e.g. gets ‘stuck’ on certain words, has difficulty getting words out, repeats sounds or words)?

Do you feel that your child has difficulties with social skills (e.g. eye contact, sharing/taking turns, difficulty making friends)?

Do you feel that your child has an unusual voice quality (e.g. ‘croaky’ voice, sounds like they always have a cold)?

Please provide more detail regarding your child’s difficulties, including when they were noticed and how this affects your child:

Please describe any behaviours your child displays that are of concern to you:

Please describe your child’s interests:

What are you hoping your child will achieve from speech therapy sessions?

Please describe any other issues that you are concerned about, or further comments you would like to add:

Finally, how did you hear about Loud and Clear Speech Pathology?

Please note that while responses are emailed directly to Loud & Clear, we cannot guarantee the security of any website. Users should be aware that the internet is an unsecure public network that gives rise to a potential risk that a user's transactions are being viewed, intercepted or modified by third parties. Please contact us should you have any questions or would prefer to provide your details in an alternative form.

Case History Form

Education

Developmental and Medical History

Concerns and Areas of Difficulty