Speech-Language Clinic Child Development Intake From. Name: Age: Birth date: Referred by: Classroom teacher(s): Any repeated grades:

Transcription

1 An equal opportunity university Communication Sciences and Disorders Bellingham, Washington (360) Fax (360) Today s Date: CLIENT INFORMATION Speech-Language Clinic Child Development Intake From Name: Age: Birth date: Referred by: Current School: Grade: Does your child attend: Preschool Day Care Public School Private School Home Schooled Classroom teacher(s): Any repeated grades: Current support service staff at school (e.g., Special Ed teachers, SLP, or OT): Private practice support professionals, if any (e.g., SLP, tutor, or counselor): Is your child on an Individualized Education or Family Service Plan (504 Plan, IEP or IFSP)? Yes No If so, describe what needs are addressed by the plan i.e. social, communication, OT, PT: Please attach plan if available. If not attached, please have your child s school send a copy to: WWU Speech-Language Clinic, 516 High Street, MS 9171, Bellingham, WA

2 FAMILY BACKGROUND Parent/Guardian s Name: Age: Occupation: Marital Status: Single Widowed Divorced Married Separated History of Speech or Language Problems? Yes No If Yes please explain: Parent/Guardian s Name: Age: Occupation: Marital Status: Single Widowed Divorced Married Separated History of Speech or Language Problems? Yes No If Yes please explain: Brothers and Sisters: Name Age Speech or Medical Problems? Were there any miscarriages? Yes No Who is currently living in the home with your child? Biological Mother Biological Father Adoptive Parents Brothers Sisters Other (please specify) Is there a family history of any of the following? Hearing Loss Speech Problem Learning Disability Autism Cleft Palate Seizure Disorder Alcoholism Drug Use Stuttering Other Social Issues Mental Health Issues If Yes please explain: Is any language other than English spoken in the home? Yes No If Yes, please list the language(s)? What is the primary language spoken at home? 2

3 Have there been any major changes in the family during the last year? Yes No If yes, please specify i.e. changes of address, change of school, parent separation/divorce, accident, illness/death, births, adoptions, marriage, etc. STATEMENT OF THE PROBLEM Describe in your own words the speech or language problem you feel your child is experiencing. When did you first notice the problem? What is your child s awareness of/reaction to the problem? How do you and other family members react to this problem? Has your child received any previous treatment for this problem? Yes No If Yes, where and from whom? What information do you hope to gain from this evaluation and what specific questions or areas do you wish us to address? PRENATAL AND BIRTH HISTORY Check any of the factors below that apply: During Pregnancy: Excessive vomiting RH Incompatibility Drug use Alcohol use Hemorrhaging Smoking Illnesses High Blood Pressure Trauma or injuries X-ray Treatments Other Was the mother on any drugs and/or medication during pregnancy? Yes No If Yes please describe: 3

4 Labor and Delivery (Please check any that apply): Full Term Normal Delivery Breeched Presentation Induced Labor Cesarean Prolonged Labor Forceps Premature: weeks early Birth Weight: Conditions affecting child after Birth (Please check any that apply): Difficulty Breathing Difficulty Sucking Difficulty Feeding Seizures Birth Defect Extended Hospital Stay Jaundice Infections Other MEDICAL HISTORY Has your child ever had the following? Ear Infection Tubes Inserted Allergies Asthma Head Injury Encephalitis Meningitis Seizures Other Please list any medications your child is currently taking and why: Does your child wear glasses? Yes No Hearing Aides? Yes No List any frequently occurring medical problems your child has. List any illnesses, injuries, or hospitalizations. Please include year. Do you suspect your child has a hearing loss? Yes No If yes what behaviors led you to suspect this? Has your child s hearing ever been tested? Yes No Location: Date 4

5 Results from hearing testing: Recommendations from hearing testing: Has your child received services from any of the following professionals? Yes If so, please indicate from whom, where and when: No Speech-Language Pathologist: Audiologist: Psychologist/Psychiatrist: Physical/Occupational Therapist: Ear, Nose, Throat Doctor: Neurologist: Opthalmologist/Optometrist: Other: Please provide a copy of any evaluation report received within the last 3 years. MOTOR DEVELOPMENT At approximately what age did your child achieve the following motor milestones? Sitting alone Crawling Standing alone Walking alone Feeding self Potty training SPEECH AND LANGUAGE DEVELOPMENT Indicate at what age your child demonstrated the following: Babbling Jargon (talking in own language) Single words Phrases Short sentences What is the primary method your child uses for letting you know what he/she wants? Some of these may not be relevant for your child current age. (please check any that apply): Looking at objects Pointing at objects Gestures and signs Crying Vocalizing Leading you to desired object Single words 2-3 Word combinations Sentences Which of the following describes your child s speech? (Please give examples) Easy to understand: Difficult for mother or parent to understand: Difficult for others to understand: Almost never understood by others: 5

6 Different than other children of the same age: If your child does not use words, please describe how s/he communicates: Which of the following statements best describes your child s reaction to his/her speech?: Is easily frustrated when not understood Does not seem aware of speech/communication problem Has been teased about his/her speech Tries to say sounds or words more clearly when asked Is successful in saying sounds or words more clearly when he/she tries Does your child have difficulty pronouncing certain sounds? Yes No If Yes, which sounds? Does your child hesitate and/or repeat sounds or words? Yes No Does your child get stuck when attempting to say a word? Yes No If so, please mark any behaviors that you have observed: Repeats individual sounds or syllables (ex. B-b-baby) Repeats single words (ex. My, my, my) Prolongs sounds (ex. Mmmmmmy) Repeats phrases (ex. Can I, can I, can I go?) Shows physical or emotional tension Blocks the sound at the beginning or middle of the word when trying to speak Is there a family history of stuttering that you are aware of? Please explain. Does your child s voice frequently sound rough or hoarse? If yes please explain. 6

7 Do you question your child s ability to understand directions or conversations? Yes No Which of the following do you think your child understands? Some of these may not be relevant for your child current age. (Please check any that apply) His/her own name Names of body parts Family names Names of objects Simple directions Complex directions Conversational speech Do you find it necessary to use gestures to help your child understand what you want? Please describe: PLAY BEHAVIORS What is the average length of time your child can stay playing at one activity? What activities seem to hold your child s attention for the longest period of time? SOCIAL AND EMOTIONAL BEHAVIOR Check the behaviors that describe your child: Overly quiet Overly active Excessive tantrums Destructive Very shy Perfectionistic Friendly/outgoing Imaginative Plays well with other children Difficulty separating from parent Please indicate how you feel about your child s behavior/development in the following areas: Balance Gross Motor Fine Motor Chewing/Swallowing Eating Social Interaction Vision Self-help skills Listening/Talking Literacy/Learning Average/Good Below average If below, please explain 7

8 EDUCATIONAL HISTORY Does your child enjoy school/child care? Yes No Please comment: Are there any concerns reported by the teacher/care provider? Yes No If so, please describe: Is your child having any difficulty with: Learning to read Spelling Telling stories Understanding emotions of others Please describe how your child interacts with peers while at school/child care: Are there any additional concerns that you have? Please provide any additional information you feel might be helpful in evaluating your child: To the best of my knowledge the information provided here is complete and factual. Signature of person completing this form Relationship to client Date Thank you for your help. Your insights will enable us to do our best for you For Office Use Only: Received By Date Received: 8