Home Our Team Service Partners Our Place Resources Pay Your Bill Contact Us Speech Therapy History Step 1 of 2 50% Form Completed By First Last Email PhoneChild's Name First Last Hearing HistoryIf your child has had ear infections, how were they treated? Tubes? Yes No How many sets?How long did they last?Antibiotics? Yes No How many courses to clear infection?Has your child’s hearing been tested? If so where and when?What were the results? Speech and Language HistoryAt your first appointment, please bring any previous evaluations and/or screening information.Has your child had a previous speech and language evaluation/screening? If yes, where was this evaluation done and by whom?Has anyone in your family had speech and language difficulties? If so, please describe below.Please check the following that apply My child babbled or cooed during the first 6 months of life My child babbled or cooed in imitation of adults, or babbled and cooed when left alone My child can combine words (two word or three word combinations) My child’s speech stopped for a period of time. Family and friends can understand my child My child can get stuck, stutter or repeat words or sounds. My child can say a nursery rhyme or is able to tell a short story My child understands what is being said to him/her. My child can follow directions. My child has trouble remembering what had been said to him/ her. My child gets frustrated by his/her communication style. My child is interested in books. My child prefers to play alone. My child prefers to play with others. When did your child say his/her first words?What were your child's first words?Number of words in your child’s expressive vocabulary if applicableWhat percentage of the time do you understand your child’s speech?What are the Communication Concerns with your child?What are your goals for Speech Therapy?How does your child communicate? (mostly gestures, mostly noises with gestures, screaming and crying with gestures, one word and gestures, 2 words, 3 words or full sentences).Does your child make sounds incorrectly? If so, what are they?What do you do when you cannot understand the message your child is giving you?Have you noticed any changes in your child’s communication in the recent weeks or months?Does your child attend playgroups/daycare/preschool? Where? How often? Is it structured or unstructured environment?How does your child interact with peers?Has any other specialist (physician, psychologist, special education teacher, etc.) seen your child? If yes, indicate the type of specialist, when your child was seen, and the specialist’s conclusions or suggestions.CommentsThis field is for validation purposes and should be left unchanged. Δ
