Name

Email

Mobile

What other languages does your child speak?

What language do they prefer to speak at home?

MEDICAL HISTORY

Other serious injuries or surgeries?

Is s/he currently (or recently) under a specialist's care? If yes, why?

Please list any medications your child takes regularly

SCHOOL HISTORY

Name of school

Year in school

What are his/her strengths and/or best subjects?

What subjects does s/he have difficulties with? Are they receiving help in these subjects?

What are his/her interests?

Does your child socialise with other children?

SPEECH LANGUAGE THERAPY

What are your concerns about your child's speech/language

Has your child ever had a speech evaluation/screening? If yes, where and when. What where you told?

Has your child ever had hearing evaluation/screening? If yes, when and where. What were you told?

Has your child ever had speech therapy? If yes, when and where. What was being worked on?

Has s/he received any other assessments or therapy? (e.g. from a physiotherapist, psychologist, occupational therapist). Please describe.

What do you see as your child's most difficult communication problem at home?

What do you see as your child's most difficult communication problem at school?

Additional Comments

Voice Culture