Connect Speech | Case History Form

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My Background
Private Therapy Overview
Adult Services
Child Services

Case History Form

The following case history information is collected to support formal and informal speech-language assessments and subsequent speech-language therapy session(s).

Name
First Last
Date of Birth
Month
Day
Year
Guardian / Parent / Spouse's Name
Age
Address
Street Address Address Line 2 City Province Postal Code
Cell Phone
Home Phone
Work Phone
Best number to call?
Preferred time of day?
Email
Sibling's Name(s) and Ages
Or
- No Siblings
How did you hear about me?
- Internet Search
- Advertisment
- Friend
- Other
Other Source
Present concern/reason for referral (please be specific about what your present concerns are and if there is a current diagnosis).
Name of Physicians or other health care professionals who you have seen (eg. Occupational Therapist, Psychologist, Physical Therapist, etc) and when did you see them?
Birth History
Were there any complications during pregnancy or delivery? If yes, please describe.
Did your child have any feeding difficulties as an infant? If yes, please describe.
Age when child:
Sat up alone:
Select an Age (in months)
Crawled:
Select an Age (in months)
Walked:
Select an Age (in months)
Started Speaking:
Age when child started combining 2-3 words to say a sentence. Select an Age (in months)
Medical History
if you check yes to any of the below, please describe any additional pertinent information (eg. year of injury, severity, medical treatment, current medications, etc)
Choose any condition
- Tongue tie
- Thumb Sucking / Finger Sucking
- Tonsillectomy
- Vision Difficulties
- Adenoidectomy
- Allergies
- Breathing Difficulties
- Ear Infections
- Ear Tubes
Choose any
- Cold/flus
- Head injury/stroke
- High Fevers
- Encephalitis
- Measles
- Meningitis
- Mumps
- Scarlet fever
- Seizures
- Sinusitis
- Sleeping Difficulties
- Other
If you checked yes to any of these, please describe any addition information.
If you checked yes to any of these, please describe any addition information.
Current Speech, Language and Social Skills Information
Language(s) spoken in the home
How does your child/teen/partner communicate with you? (eg. pointing, words, sentences, etc)
Does your child/teen/partner or yourself enjoy interacting/engaging with others?
What activities/hobbies does your child/teen/partner or yourself enjoy?
What speech sounds (eg. s, r, p, t, etc) and/or language skills (eg. grammar, sentence formation, vocabulary, problem solving, etc) are you concerned with?
Are there any behaviours you are concerned with (eg. spending extended periods of time alone, difficulty interacting with others, etc)?
School History (complete if applicable)
Name of School
Current Grade
Grades Repeated
Is your child/teen/partner aware of or frustrated by the communication problem?
- Yes
- No
Where are your child's/teens/partners academic strengths?
How do they feel about it? How do they react?
Additional Comments
Please upload any professional reports that may benefit your child/teen/partners therapy
Drop files here or

Accepted file types: pdf, jpg, Max. file size: 20 MB, Max. files: 5.
Please provide any other information that you believe may benefit your child/teen/partners therapy
Thank you for completing this form. I look forward to connecting with you soon.

Connect Speech

Language Therapy Services
Email: info@connectspeechtherapy.com
Phone: (639)590-4312

Services

-Fees & Services
-Booking an appointment
-Cancellation Policy
-What to expect

Pamela Lamon

MS, SLP-C, CCC-SLP
Registered in Saskatchewan
Certified Speech-Language Pathologist

© 2019 Connect Speech- Language Therapy Services