Child's Name *
Child's Name
Date of Birth *
Date of Birth
Address *
Address
Phone *
Phone
Can we contact you via email? *
Address *
Address
Address (if different)
Address (if different)
Has the child had any previous speech/language therapy? *
Is the child receiving speech/language therapy at the present time? *
Developmental and Medical History
Were there illnesses or unusal events that occurred during this pregnancy? *
Was labor and delivery normal? *
During pregnancy with this child was there
Was the child full term? *
Problems with:
Problems during the first month? *
Has the child had any feeding difficulties? *
Did child suck thumb or use pacifier?
Has the child ever had a hearing evaluation?
Does your child wear glasses?
Does your child have any of the following?
Were there any after effects from the above illnesses?
Is your child taking medication?
Speech and Language History
If yes, please describe.
How does your child usually communicate?
Is your child able to understand...
Is your child aware of difficulties?
If yes, please describe.
If yes, please describe.
At what ages did the child first demonstrate the following speaking behaviors?
If yes, please describe.
If yes, please describe.
If yes, please describe.
If yes, please describe.
School History
If the child has had problems in school, please describe.

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