Child's Name:

    Date of Birth:

    Phone:

    Address:

    City:

    State:

    Zip:

    Did the child live with the birth parents?

    Reason for Referral

    Siblings (names and ages)

    Primary Language of the Child

    Any other languages spoken in the home (please list)?

    Does the child present a speech-language, nutritional, fine motor, feeding, swallowing, weight, sensory, or hearing concern (please explain)?

    Does anyone in the family have similar concerns (please explain)?

    Is your child currently receiving any other therapy in the community (what type and where)?

    How does the child usually communicate (gestures, single words, short phrases, sentences)?

    When was the problem(s) first noticed (by whom)?

    Is the child aware of the problem(s)? If so, how do they feel about it?

    Prenatal and Birth History

    Mother's general health during pregnancy (illnesses, accidents, medications, etc.)

    Length of Pregnancy:

    General Condition:

    Length of Labor:

    Birth Weight:

    Medical History

    If applicable, please provide the approximate ages at which the child had the following illnesses/conditions.

    Asthma:

    Croup:

    Ear Infection:

    Headaches:

    Mastoiditis:

    Measles:

    Pneumonia:

    Tinnitus:

    Colds:

    Draining Ears:

    Has the child had any surgeries or diagnostic tests? If so, what type and when?

    Describe any major accidents or hospitalizations.

    Is the child taking any medications? If so, please identify.

    Developmental History

    If applicable, please provide the approximate ages at which the child began the following activities.

    Crawl:

    Sit:

    Stand:

    Walk:

    Feed Self:

    Dress Self:

    Use Toilet:

    Use Single Words:

    Combine Words:

    Name Simple Objects:

    Ask Simple Questions:

    Engage in Conversations:

    How does the child interact with others (shy, aggressive, etc.)?

    Family History
    If applicable, please list any family members with the following diagnoses.

    Autism:

    ADHD:

    Bi-Polar Disorder:

    Depression:

    Schizophrenia:

    Anxiety:

    OCD:

    ODD:

    Other:

    Has the patient experienced recent physical/emotional trauma or major life changes (divorce, deaths, moving, etc.). If so, please explain.

    Patient's Strengths and Weaknesses

    Patient preferences and familiar things

    Top 3 goals/areas you would like to see change or improve for your child over the next 6 months

    Person Completing Form:

    Relationship to Child:

    Document(s):

    Child Case History Form