To prepare for your child’s assessment, please fill out the background information below. If not applicable please leave blank. Name of Mother First Name Last Name Name of Father First Name Last Name Childs Name Email * Mobile Address Address 1 Address 2 City State/Province Zip/Postal Code Country Child's Date of Birth MM DD YYYY Who does the child live with? Birth Parent/s Adoptive Parents Foster Parents Step Parent Sibling Relative Other What other languages are spoken at home? If yes, does the child understand the language? Yes No Somewhat Does the child speak the language? Yes No Somewhat What language does the child prefer to speak at home? BIRTH HISTORY Childs birth weight Was the child healthy at birth? How many months was the pregnancy? Was there anything unusual about the pregnancy or birth? Please describe. Was the Mother sick during the pregnancy? Please describe MEDICAL HISTORY Has your child had any of the following? Adenoidectomy Allergies Breathing difficulties Chicken Pox Colds Ear Infections Grommets Encephalitis Flu Head Injury High Fevers Measles Meningitis Scarlet Fever Seizures Sinusitis Sleeping Difficulties Thumb/Finger Sucking Habit Tonsillectomy Tonsillitis Vision Problems 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 DEVELOPMENTAL HISTORY Please tell the approximate age your child achieved the following developmental milestones... Sat unassisted Babbled Put two words together Walked Grasped crayon/pencil Said first words Spoke in short sentences Was toilet trained Was s/he breast fed? If so for how long? Did your child have difficulty sucking? Yes No Did your child dribble excessively? Yes No Does your child prefer a soft food diet? Yes No Does your child have difficulty chewing? Yes No Does your child choke on foods or liquids? Yes No Does your child currently put toys/objects in his/her mouth? Yes No Does your child brush (or allow brushing of) his/her teeth? Yes No PRESCHOOL HISTORY Name of preschool Please leave blank if not applicable What are his/her interests? (What does s/he enjoy doing?) Does your child socialise with other children? SCHOOL HISTORY (if in school) Please leave blank if not applicable Name of school Year in school Has s/he repeated a year? If so which year? 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? CURRENT SPEECH LANGUAGE Does your child: Please check relevant boxes Repeat sounds, words or phrases over and over? Understand what you are saying? Give or point to common objects upon request (e.g. ball, cup, shoe)? Follow simple directions (e.g. "Shut the door." Or "Get your shoes") Respond correctly to yes/no questions? Respond correctly to who/what/where/when/why questions? Does your child currently communicate using: Please check relevant boxes Body language/pointing Sounds (e.g. vowels, grunting) Single words (e.g. shoe, doggy, up) 2 - 4 word sentences Sentences longer than 4 words Behavioural Characteristics Please check relevant boxes Cooperative Attentive Willing to try new activities Plays alone for reasonable lengths of time Separation difficulties Easily frustrated Impulsive Stubborn Restless Poor eye contact Easily distracted/short attention Destructive Aggressive Withdrawn Inappropriate behaviour Self-abusive behaviour 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 your child seen a paediatrician? Yes No Has s/he received any other assessments or therapy? (e.g. from a physiotherapist, psychologist, occupational therapist). Please describe. Is the child aware of or frustrated by the speech or language difficulties? Yes No 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 Thank you for completing the information.We look forward to working with you and your child to achieve your communication goals.
