Identifying and Family Information:

Child’sName:                                               Birthdate:                             Sex: M F

 Father’s Name:         Daytime Phone:                                                               Address:         Cell Phone:                 


Mother’s Name:         Daytime Phone:                                         Address:         Cell Phone:         


Doctor’s Name:         Doctor’s Phone:          

Child lives with (check one):

 Birth Parents

 Adoptive Parents

 Foster Parents

 Parent and Step-Parent

 One Parent


Other children in the family:

Name        Age        Sex        Grade        Speech/Hearing Problems

Child’s race/ethnic group:

 Caucasian, Non-Hispanic

 Native American


 Asian or Pacific Islander



Is there a language other than English spoken in the home?        Yes        No

If  yes, which one?                          Does the child speak the language?        Yes        No

Does the child understand the language?        Yes        No

Who  speaks the language?            Which language does the child prefer to speak at home?          


        Do you feel your child has a speech problem?        Yes        No

If  yes,  please describe.          

Do you feel your child has a hearing problem?        Yes        No

If  yes,  please describe.          

Has he/she ever had a speech evaluation/screening?        Yes        No

If yes, where and when?           What were you told?          

Has he/she ever had a hearing evaluation/screening?        Yes        No

If yes,  where and when?           What were you told?          

Has your child ever had speech therapy?        Yes        No

If yes,  where and when?           What was he/she working on?          

Has your child received any other evaluation or therapy (physical therapy, counseling, occupational therapy, vision, etc.)?        Yes        No

If yes, please describe.         

Is your child aware of, or frustrated by, any speech/language difficulties?         

What do you see as your child’s most difficult problem in the home?          

What do you see as your child’s most difficult problem in school?         

Was there anything unusual about the pregnancy or birth?        Yes        No

If yes, please describe.          

How old was the mother when the child was born?          

Was the mother sick during the pregnancy?        Yes        No

If  yes,  please describe.          

How many months was the pregnancy?         

Did the child go home with his/her mother from the hospital?        Yes        No

If child stayed at the hospital, please describe why and how long.          

Did the child ever use a pacifier?           Yes        No

Does the child still use a pacifier?  Yes        No

           If no, please indicate at what age the child no longer utilized a pacifier? _____________________

Has your child had any of the following?

 adenoidectomy        encephalitis        seizures

 allergies        flu        sinusitis

 breathing difficulties        head injury        sleeping difficulties

 chicken pox        high fevers        thumb/finger sucking habit

 colds        measles        tonsillectomy

 ear infections        meningitis        tonsillitis

How often?                 mumps        vision problems

 ear tubes        scarlet fever

Other serious injury/surgery:          

Is your child currently (or recently) under a physician’s care?        Yes        No

If yes, why? 

       Please list any medications your child takes regularly:           

Please list any known allergies:           

Please tell the approximate age your child achieved the following developmental milestones:

          sat alone                 grasped crayon/pencil

          babbled                 said first words

          put two words together                 spoke in short sentences

          walked                 toilet trained

Does your child...

 choke on food or liquids? ___________________________

 currently put toys/objects in his/her mouth? _____________________

 brush his/her teeth and/or allow brushing? ______________________

        use a spoon? ___________________

        type of cup used (circle all that apply):  sippy    open cup   360   straw   other? _____________

Does your child...

 repeat sounds, words or phrases over and over?

 understand what you are saying?

 retrieve/point to common objects upon request (ball, cup, shoe)?

 follow simple directions (“Shut the door” or “Get your shoes”)?

 respond correctly to yes/no questions?

 respond correctly to who/what/where/when/why questions?

Your child currently communicates using...

 body language.

 sounds (vowels, grunting).

 words (shoe, doggy, up).

 2 to 4 word sentences.

 sentences longer than four words.

 other         .

Behavioral Characteristics:

 cooperative        restless

 attentive        poor eye contact

 willing to try new activities        easily distracted/short attention

 plays alone for reasonable length of time        destructive/aggressive

 separation difficulties        withdrawn

 easily frustrated/impulsive        inappropriate behavior

 stubborn        self-abusive behavior

If your child is in school, please answer the following:

Name of school and grade in school:            

Teacher’s  name:           

Has your child repeated a grade?          

What are your child’s strengths and/or best  subjects?          

Is your child having difficulty with any subjects?          

Is your child receiving help in any subjects?