Pediatric Case History Form

Pediatric Case History Form

Speech-Language Therapy, Occupational Therapy, and/or Physical Therapy
Demographic Information
Date of Form Completion:*

MonthDayYear
Date
Client's Name*

First NameLast Name
Client's Date of Birth*

MonthDayYear
Date
Age*
Gender
Diagnosis (if known)
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Phone*
Please enter a valid phone number.
Parent/Guardian Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone*
Please enter a valid phone number.
Client/Child's Doctor's Name*

First NameLast Name
Doctor's Practice Name*
Doctor's Phone
Please enter a valid phone number.
Doctor's Fax:
Practice Location

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Insurance *
Insurance Member #*
How Did you Hear About Communication Cottage Therapy, LLC?*

Family Background
Status*

singlemarrieddivorcedseparatedwidowedOther
Parent #1 Name*

First NameLast Name
Parent #1 Age*
Parent #1 Occupation*
Parent #1 Education Level*
Parent #2 Name*

First NameLast Name
Parent #2 Age*
Parent #2 Occupation*
Parent #2 Education Level*
What adults does the child live with? (parent 1, parent 2, grandparents... etc)*
Does the Child have any siblings? Please indicate name, age, gender, and if they live in the home. *
Any known speech delays/difficulties or motor difficulties with the child's sibling(s) that may be pertinent to know at this time.*
Language(s) spoken in the home*
Who speaks the other languages
Primary Language in home*
Describe the Child's use of the language and understanding of the language
Is there anything additional that you would like to share about the family/home environment?*

Evaluation
Briefly describe why you're seeking an evaluation at this time*
What are you expecting out of this evaluation/meeting?*
Has the child had a previous evaluation of OT, ST, or PT services?*

yesno
If yes, for which discipline, by whom and when?
Describe the Results of the Evaluation
If you have a copy of the Evaluation (upload here) *if applicable

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Previous Care Plan (upload here) *if applicable

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Discharge Summary (upload here) *if applicable

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Describe in your own words the nature of your concerns about the child's development and/or the primary referral reasons?*
At what age did you first notice the problem?*
How do the child's delays in their developmental skills impact the family?*
If anyone else in the family had a speech/language or motor delay? Please describe:
Is the child aware or frustrated by their communication/motor/sensory difficulties?*

Social History
Who does the child interact with on a daily basis*
How does the child interact with family?*
How does the child interact with someone new?*
Describe Communication Difficulties in the home environment*
Any Significant events or changes within the home?*
Child's Strengths*
Child's Weaknesses/Areas to Grow*
Does the child participate in community activities?*
What are the child's favorite activities?*
Does the child become easily frustrated with activities?*
What are your goals for your child over the next 6 months?*
What are your goals for your child over the next 5 years?*
Is there anything else that is important for us to know about your child that will help us to get to know them better and better meet them where they are at and help bridge the gap with their communication skills?*
Please upload any other pertinent background documents/records

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Person Completing the Form*

First NameLast Name
I acknowledge that this form will be utilized to assist the evaluating therapist complete the background section of the evaluation. I have provided as accurate information as possible to help guide the treatment of this child. *

Clear
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Demographic Information