Minor Speech Therapy Case History

Minor Speech Therapy Case History

Please complete this intake form for a minor speech therapy case history.
Patient Information
Patient Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Parent/Guardian Name
Parent/Guardian Email
example@example.com
Primary Parent/Guardian Phone Number
Referral and Reason for Referral
Referral Source

Other
Reason for Referral
Medical History
Birth history normal at birth and during newborn period?
Birth history details
Were early developmental milestones met on time? (walking, crawling, babbling, 1st words, combining words)
If any milestones were delayed, please explain
Current or past medical conditions

Other
If a diagnosis is checked, please indicate the estimated age at the time of diagnosis
Does the child take any medications?
Medication names and dosages
Speech and Language Concerns
Describe the current speech and language concerns
When did the concerns first begin?
Which areas are affected?

Other
Overall severity of the concerns

1

2

3

4

5

6

7

8

9

10

1 is Mild, 10 is Severe
Family and Social History
Household / Living situation

Other
Any family history of speech or language difficulties?
Social communication concerns or relevant family/social background details
Educational History
School/Daycare Name
Grade/Program Level
Supports/Services Received

Other
Teacher/School Observations and Classroom Concerns
Previous Evaluations and Therapies
Has the child had any previous speech or language evaluations/treatment?
Provider name for previous speech or language evaluation
Date of previous speech or language evaluation

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Findings, recommendations, and current or past speech/language services
Should be Empty:

Minor Speech Therapy Case History

Patient Information

Referral and Reason for Referral

Medical History

Speech and Language Concerns

Family and Social History

Educational History

Previous Evaluations and Therapies