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Phone: (407) 205-7377
Fax: (407) 563-8458
info@orlandospeechtherapy.com
www.orlandospeechtherapy.com

Notice of Protected Health Information Privacy Practices

Generalized Consent for Treatment

 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOUR CHILD MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. 

PLEASE REVIEW IT CAREFULLY.

When I refer to “you” or “your” below, it represents your child or the patient receiving services from Orlando Speech Therapy.  The initials OST are used to represent Orlando Speech Therapy.

As part of the healthcare service you receive from Orlando Speech Therapy, health records are generated and maintained describing your child’s care including, but not limited to, your name, address, phone number, social security number, health history, symptoms, examination and test results, diagnoses, procedures, treatments, and plans for future care or treatment. This information is called “Protected Health Information” (PHI). This Notice of Privacy Practices describes how Orlando Speech Therapy may use and disclose your information and the rights that you have regarding your health information.

Uses and Disclosures of Health Information Without Authorization

When you obtain services from Orlando Speech Therapy, certain uses and disclosures of your health information are necessary and permitted by law in order to treat you, to process payments for your treatment, and to support the operations of the entity and other involved providers. The following categories describe ways that we use or disclose your information, and some representative examples are provided in each category. All of the ways your health information is used or disclosed should fall within one of these categories.

  • Your health information will be used for treatment: For example: Disclosure of medical information about you may be made to therapists, doctors, nurses, technicians, or others who are involved in treating you. This information may be disclosed to other physicians who are treating you or to other healthcare facilities involved in your care. Information may be shared with pharmacies, laboratories, or radiology centers for the coordination of different treatments.  
  • Your health information will be used for payment: For example: Health information about you may be disclosed so that services provided to you may be billed to an insurance company or a third party for reimbursement of services rendered. Information may be provided to your health plan about treatment you are going to receive in order to obtain prior approval or to determine if your health plan will cover the treatment.  
  • Your health information will be used for health care operations: For example: This information in your health record may be used to evaluate and improve the quality of the care and services we provide.  

Disclosures Required by Law or Otherwise Allowed Without Authorization or Notification

 

The following disclosures of health information may be made according to state and federal law without your written authorization or verbal agreement:

  • When a disclosure is required by federal, state, or local law, judicial or administrative proceedings, or for law enforcement; examples would be reporting gunshot wound or child abuse, or responding to court orders
  • For public health purposes, such as reporting information about births, deaths, and various diseases, or disclosures to the FDA regarding adverse events related to food, medications, or devices
  • For health oversight activities, such as audits, inspections, or licensure investigations
  • To organ procurement organizations for the purpose of tissue donation and transplant     
  • To avoid a serious threat to the health or safety of a person or the public
  • Contacting you to provide appointment reminders or to recommend treatment alternatives
  • Notifying you of health-related benefits and services that may be of interest to you

Required Uses and Disclosures: Under the law, we must make disclosures when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with federal privacy law.

Uses and Disclosures Requiring Authorization

Any other uses or disclosures of your health information not addressed in this Notice or otherwise required by law will be made only with your written authorization. You may revoke such authorization at any time.

YOUR INDIVIDUAL RIGHTS UNDER HIPAA

  • You have the right to request restrictions on certain uses and disclosures of your Protected Health Information. For example, you may wish to restrict your employer from knowing about a medical condition. Regardless of your request, please know that the HIPAA rules allow our office to share your Protected Health Information with the Covered Entities.  If you wish to restrict your PHI please make this request in writing to OST and discuss with your therapist.
  • You have the right to receive your Protected Health Information in a confidential communication from our office, such as the US mail.  If you have a specific request for communication please discuss this with your therapist or Amy Vaughn, OST owner.
  • You have the right to inspect and copy your Protected Health Information. Copies of your Protected Health Information are available for a reasonable fee paid to our office to cover our expenses of reproducing them.  You may request this information at any time via your therapist, the office manager, or Amy Vaughn, OST owner.
  • You have the right to request that we amend your Protected Health Information. In some cases, we may require that these requests be in writing and be supported by a reason for the change. Generally, this will not apply to such routine changes as address or phone number listings.
  • You have the right to receive, upon request, an accounting of your Protected Health Information that we have provided to Non-Covered entities.
  • If you have read and responded to this notice through electronic media such as our website or email, you have the right to receive a paper copy of this notice upon request.

 

If you would like to exercises any of these rights, please contact Amy Vaughn (OST owner) at (407) 205-7377 and we will make any necessary arrangements for you.

Orlando Speech Therapy is required by law to maintain the privacy of your Protected Health Information and to provide you with this notice of our legal duties and privacy practices as they apply to your Protected Health Information. We are also required to abide by the terms of this notice, which is currently in effect as of December 15, 2012. 

In the future, we reserve the right to change the terms contained in this notice and make any new provisions effective for all of the Protected Health Information we maintain. In the event we elect to change the terms of this notice, a new notice will be posted in our office. In addition, you may receive notification by direct mail, email, or other such communication as our practice may implement from time to time.

      

Should you ever believe your privacy rights have been violated, we request you to file a complaint with our office by contacting us at (407) 205-7377 or by mail to: 6001 Vineland RD Suite 109 Orlando, FL 32819. You may also register your complaint with the Secretary of the US Department of Health and Human Services, Office of Civil Rights. As part of our commitment to you, we value your privacy and take every precaution in our practice to preserve your right to that privacy. Any complaint you file will be used strictly to improve our operating procedures and in no way will you be retaliated against for filing a complaint.            

Should you have any questions or concerns, please contact OST owner, Amy Vaughn, directly at (407) 205-7377 to obtain further information.

Generalized Consent for Treatment

I have read and understand the Notice of Protected Health Information Privacy Practices for Orlando Speech Therapy.  I understand that if I do not sign this consent form my child cannot be evaluated or treated by Orlando Speech Therapy.

When Orlando Speech Therapy examines, diagnoses, treats, or refers your child, we will be collecting what the law calls Protected Health Information (PHI) about your child.  We need to use this information to decide on what treatment is best for your child, provide treatment to your child, and collect payment. We may also share this information with others who provide treatment to your child or need it to arrange payment for your child’s treatment or for other business or government functions. 

By checking below you are agreeing to let me use your child’s Protected Health Information (PHI) for the purposes of payment, treatment, and health care operations.  You are also agreeing to allow communications via email, text messages, voice mail and telephone, which may contain your child’s PHI.

I Agree
 

Payment Agreement

At Orlando Speech Therapy we are committed to providing your child with the utmost in quality rehabilitative services.  In order to maintain this level of standard practice, timely payment must be received for services rendered.  Payment is expected at the time of service unless other arrangements have been made in advance, or we are attempting to bill your insurance company.  Please note that insurance coverage does not guarantee payment for speech-language services rendered.   If your insurance company denies payment for any reason, you will be billed the contracted rate.

  • For Privately Paying Patients: Payment will be due at the time of service according to our current rate schedule.
  • For Patients With In-Network Insurance and Medicaid: 
    • Proof of insurance is required prior to your first appointment so that we may gather benefit information and obtain prior authorization if required to do so by your carrier.  
    • Any co-pays and/or deductibles are expected at the time of service.  This is legally required as per your contract with the insurance company.  
    • We will submit therapy claims on your behalf, but please note this is not a guarantee of payment.  If your insurance company denies part, or all, of the therapy claim, you will be billed at the contracted rate for your carrier.  
    • We will make reasonable effort to assist you in collecting payment from your insurance carrier.  If your insurance company requires submission of information from you directly, you will be expected to do so in a timely manner.  Claims that remain unpaid after 60 days will be billed to you directly.  
    • Your insurance benefit is a contract between you and your insurance company; we are not party to that contract.  If you have questions about your insurance benefits, please contact your carrier directly.  We will happy to provide you with any necessary procedure and diagnosis codes they may require to answer your questions.
       
  • For Patients With Out-of-Network Insurance:
    • Payment is due at the time of service using our current rate schedule. 
    • We can provide you (upon request) with a receipt/ invoice containing proper coding that you can submit directly to your insurance carrier.  
    • Your insurance benefit is a contract between you and your insurance company; we are not party to that contract.  If you have questions about your insurance benefits, please contact your carrier directly. 
  • Non‐Payment: Account balances are expected to be paid prior to your next scheduled therapy session unless other payment arrangements have been made with Amy Vaughn, Orlando Speech Therapy, owner.  If your account has not been paid in full within 15 days, therapy will be put on hold until payment has been made.  If your account has not been paid within 30 days, a late charge of $25.00 will be applied to your account balance, and every subsequent 30 days thereafter.  In the event that we turn this matter over to a collection agency or to an attorney, all fees and costs incurred will be your responsibility.
     
  • No-Show / Missed Appointment Fees: While we strive for regular attendance, we understand that children get sick and situations arise which will result in the need to cancel your appointment.  Please do us the courtesy of giving us as much notice as is possible.  Sessions cancelled within 2 hours may be subject to a no-call / no-show fee.  Sessions missed without notification will be billed the no-call / no-show fee of $25.00.  Payment for this fee will be required prior to your next scheduled therapy session.  

I read, understand, and agree to comply with the Payment Agreement of Orlando Speech Therapy.

I Agree
 

Attendance Agreement

At Orlando Speech Therapy we are committed to providing your child with the utmost in quality rehabilitative services.  In order to maintain this level of standard practice, regular attendance is essential.  Progress can only occur when children attend their sessions regularly and home carryover is completed.

We also understand that children get sick and situations arise which will result in the need to cancel your appointment.  Please do us the courtesy of giving us as much notice as is possible.  Sessions cancelled within 2 hours of your scheduled appointment may be subject to a fee and may be recorded as an unexcused absence.

After 3 unexcused absences, your child will be placed on a “will call” list.  Your child will no longer be scheduled in a regular weekly time slot.   We will call to schedule appointments when we have a cancellation that allows for an opening in the schedule.      

We appreciate your understanding of this policy.  We are committed to the children we serve and are devoted to the development of their speech and language.  In order to allow all children the opportunity to receive therapy, we cannot hold spots for clients who cancel excessively or who have 3 “no-call, no-show” appointments. It is imperative to maintain an attendance percentage of 80% or higher over the course of a 2-month time frame.

Thank you for your help in upholding this policy and ensuring your child attends therapy regularly and consistently.  This will only help to maximize the results from the therapy they receive. 

I Agree
 

First Patient Name

First Name*

Last Name*
First Patient Date of Birth*
I certify that I am 18 years of age or older
First Patient Case History and Background Information

Family History


Language(s) spoken in the home: *

Child's primary caregiver(s):

Parent's Full Name: *

Date of Birth:

Occupation:

E-mail address: *

Primary phone: *

Secondary phone:

Significant Medical history:

Parent's Full Name:

Date of Birth:

Occupation:

E-mail address:

Primary phone:

Secondary phone:

Significant Medical history:

Siblings: Name / Date of Birth / School and grade


1.

2.

3.

Is there any family history of difficulties similar to those your child is experiencing? Is there any family history of language, learning or developmental delays? If so, please describe. *

Pregnancy and Delivery


Mother's age at time of pregnancy:

Mother's general health during pregnancy:
Any difficulties with the pregnancy?*
No
Yes

If yes, please describe.

Please list any drugs or medications taken during pregnancy. *

Duration of pregnancy in weeks: *
Type of Labor:*

Duration:
Type of delivery:*

Other:

Please describe any labor and delivery complications. *

Birth weight: *

Apgar score:

Child's health post delivery:
Did baby accompany mother home from the hospital?*
No
Yes

If no, please explain.

Mother's health post delivery:

Medical History

If your child's medical history includes any of the following, please report the child's age at occurrence, number of occurrences and any other pertinent information.

Check all that apply
Accidents
Allergies
Asthma
Childhood diseases
Colds (persistent)
Colic
Ear infections
Eye infections
High fevers (persistent)
Hospitalizations
Operations
Seizures
Sinusitis
Throat infections
Tonsillitis
Other

If any checked, please provide additional information:

Medications your child takes regularly and what they are used for: *

Has your child's hearing been tested? If yes, when and what were the results. *

How many ear infections has your child suffered? *
Does your child hear you when his/her back is turned?*
No
Yes
Does your child hear you from another room?*
No
Yes
Does your child hear in a noisy environment?*
No
Yes

Developmental History

At approximately what age did your child do the following?

Early / Average / Late

Sit*
Early
Average
Late
Crawl*
Early
Average
Late
Walk*
Early
Average
Late
Babble*
Early
Average
Late
Use single words*
Early
Average
Late
Combine 2 words*
Early
Average
Late
Use phrases*
Early
Average
Late
Use sentences*
Early
Average
Late
Ask questions*
Early
Average
Late
Engage in Conversation*
Early
Average
Late

Describe your child as a baby (fussy, happy, easy or difficult to sooth, cried a lot, alert, cuddly, sociable, lethargic, etc.).

Communication Development

When you talk to your child, how much do you feel is understood?*
How does your child communicate wants and needs? Check all that apply. *
cries
points
signs
pulls toward object
gestures
vocalizes sounds
uses single words
uses many words, but only one at a time
uses phrases
uses long sentences
Does your child answer when you call?*
No
Yes
Does your child answer yes/no and wh- questions?*
No
Yes
Does your child ask for help?*
No
Yes
Does your child talk about what he/she is doing?*
No
Yes
What percentage of your child's speech do you understand?*
No
Yes
Can people outside the family understand your child's speech?*
No
Yes
Does your child stutter or stammer?*
No
Yes

Did you ever notice a change in your child's behavior, language, or social skills? If so, please describe the change and when it occurred. *

How does your child gain attention? *

Does your child have any sensory difficulties (tactile, visual, auditory etc.)? If yes, please describe. *

Feeding (if applicable)


Was your child breastfed or bottle-fed?

Was your child weaned to bottles, cups, or both?

Does your child drink from bottles, sippy cups, straws, or open cups?

Does your child use utensils independently?

Was feeding your child ever difficult? If so, please explain.

Does your child have any difficulty sucking, chewing, or swallowing? Please describe.

Is your child a picky or fussy eater?
Does your child eat a variety of foods? Please check all that apply.
soft
chewy
crunchy
sticky
cold
fruits
sweet
pureed
meats
vegetables
spicy
hot
breads
sour
dairy

If your child does not eat a variety of foods, please describe current diet.

Present Concerns


Please describe your concerns regarding your child's speech, language, feeding, play, and/or social development. *
Is your child aware of the problem?*
No
Yes

When did you first notice the difficulty? *

Has the problem changed since you first noticed? *
Does your child's communication difficulty cause frustration?*
No
Yes

Has your child ever been evaluated for therapeutic services? If yes, when and what were the recommended services? *

Has your child ever received any therapeutic interventions? If yes, please indicate which type (SP, OT, PT, EI, ABA etc.), when services began, and with whom. *
Does your child currently attend school or group activities?*
No
Yes

How do his/her peers and teachers react to the communication difficulty?

Any additional comments or questions?
First Patient Signature*
Second Patient Name

First Name*

Last Name*
Second Patient Date of Birth*
Second Patient Case History and Background Information

Family History


Language(s) spoken in the home: *

Child's primary caregiver(s):

Parent's Full Name: *

Date of Birth:

Occupation:

E-mail address: *

Primary phone: *

Secondary phone:

Significant Medical history:

Parent's Full Name:

Date of Birth:

Occupation:

E-mail address:

Primary phone:

Secondary phone:

Significant Medical history:

Siblings: Name / Date of Birth / School and grade


1.

2.

3.

Is there any family history of difficulties similar to those your child is experiencing? Is there any family history of language, learning or developmental delays? If so, please describe. *

Pregnancy and Delivery


Mother's age at time of pregnancy:

Mother's general health during pregnancy:
Any difficulties with the pregnancy?*
No
Yes

If yes, please describe.

Please list any drugs or medications taken during pregnancy. *

Duration of pregnancy in weeks: *
Type of Labor:*

Duration:
Type of delivery:*

Other:

Please describe any labor and delivery complications. *

Birth weight: *

Apgar score:

Child's health post delivery:
Did baby accompany mother home from the hospital?*
No
Yes

If no, please explain.

Mother's health post delivery:

Medical History

If your child's medical history includes any of the following, please report the child's age at occurrence, number of occurrences and any other pertinent information.

Check all that apply
Accidents
Allergies
Asthma
Childhood diseases
Colds (persistent)
Colic
Ear infections
Eye infections
High fevers (persistent)
Hospitalizations
Operations
Seizures
Sinusitis
Throat infections
Tonsillitis
Other

If any checked, please provide additional information:

Medications your child takes regularly and what they are used for: *

Has your child's hearing been tested? If yes, when and what were the results. *

How many ear infections has your child suffered? *
Does your child hear you when his/her back is turned?*
No
Yes
Does your child hear you from another room?*
No
Yes
Does your child hear in a noisy environment?*
No
Yes

Developmental History

At approximately what age did your child do the following?

Early / Average / Late

Sit*
Early
Average
Late
Crawl*
Early
Average
Late
Walk*
Early
Average
Late
Babble*
Early
Average
Late
Use single words*
Early
Average
Late
Combine 2 words*
Early
Average
Late
Use phrases*
Early
Average
Late
Use sentences*
Early
Average
Late
Ask questions*
Early
Average
Late
Engage in Conversation*
Early
Average
Late

Describe your child as a baby (fussy, happy, easy or difficult to sooth, cried a lot, alert, cuddly, sociable, lethargic, etc.).

Communication Development

When you talk to your child, how much do you feel is understood?*
How does your child communicate wants and needs? Check all that apply. *
cries
points
signs
pulls toward object
gestures
vocalizes sounds
uses single words
uses many words, but only one at a time
uses phrases
uses long sentences
Does your child answer when you call?*
No
Yes
Does your child answer yes/no and wh- questions?*
No
Yes
Does your child ask for help?*
No
Yes
Does your child talk about what he/she is doing?*
No
Yes
What percentage of your child's speech do you understand?*
No
Yes
Can people outside the family understand your child's speech?*
No
Yes
Does your child stutter or stammer?*
No
Yes

Did you ever notice a change in your child's behavior, language, or social skills? If so, please describe the change and when it occurred. *

How does your child gain attention? *

Does your child have any sensory difficulties (tactile, visual, auditory etc.)? If yes, please describe. *

Feeding (if applicable)


Was your child breastfed or bottle-fed?

Was your child weaned to bottles, cups, or both?

Does your child drink from bottles, sippy cups, straws, or open cups?

Does your child use utensils independently?

Was feeding your child ever difficult? If so, please explain.

Does your child have any difficulty sucking, chewing, or swallowing? Please describe.

Is your child a picky or fussy eater?
Does your child eat a variety of foods? Please check all that apply.
soft
chewy
crunchy
sticky
cold
fruits
sweet
pureed
meats
vegetables
spicy
hot
breads
sour
dairy

If your child does not eat a variety of foods, please describe current diet.

Present Concerns


Please describe your concerns regarding your child's speech, language, feeding, play, and/or social development. *
Is your child aware of the problem?*
No
Yes

When did you first notice the difficulty? *

Has the problem changed since you first noticed? *
Does your child's communication difficulty cause frustration?*
No
Yes

Has your child ever been evaluated for therapeutic services? If yes, when and what were the recommended services? *

Has your child ever received any therapeutic interventions? If yes, please indicate which type (SP, OT, PT, EI, ABA etc.), when services began, and with whom. *
Does your child currently attend school or group activities?*
No
Yes

How do his/her peers and teachers react to the communication difficulty?

Any additional comments or questions?
Third Patient Name

First Name*

Last Name*
Third Patient Date of Birth*
Third Patient Case History and Background Information

Family History


Language(s) spoken in the home: *

Child's primary caregiver(s):

Parent's Full Name: *

Date of Birth:

Occupation:

E-mail address: *

Primary phone: *

Secondary phone:

Significant Medical history:

Parent's Full Name:

Date of Birth:

Occupation:

E-mail address:

Primary phone:

Secondary phone:

Significant Medical history:

Siblings: Name / Date of Birth / School and grade


1.

2.

3.

Is there any family history of difficulties similar to those your child is experiencing? Is there any family history of language, learning or developmental delays? If so, please describe. *

Pregnancy and Delivery


Mother's age at time of pregnancy:

Mother's general health during pregnancy:
Any difficulties with the pregnancy?*
No
Yes

If yes, please describe.

Please list any drugs or medications taken during pregnancy. *

Duration of pregnancy in weeks: *
Type of Labor:*

Duration:
Type of delivery:*

Other:

Please describe any labor and delivery complications. *

Birth weight: *

Apgar score:

Child's health post delivery:
Did baby accompany mother home from the hospital?*
No
Yes

If no, please explain.

Mother's health post delivery:

Medical History

If your child's medical history includes any of the following, please report the child's age at occurrence, number of occurrences and any other pertinent information.

Check all that apply
Accidents
Allergies
Asthma
Childhood diseases
Colds (persistent)
Colic
Ear infections
Eye infections
High fevers (persistent)
Hospitalizations
Operations
Seizures
Sinusitis
Throat infections
Tonsillitis
Other

If any checked, please provide additional information:

Medications your child takes regularly and what they are used for: *

Has your child's hearing been tested? If yes, when and what were the results. *

How many ear infections has your child suffered? *
Does your child hear you when his/her back is turned?*
No
Yes
Does your child hear you from another room?*
No
Yes
Does your child hear in a noisy environment?*
No
Yes

Developmental History

At approximately what age did your child do the following?

Early / Average / Late

Sit*
Early
Average
Late
Crawl*
Early
Average
Late
Walk*
Early
Average
Late
Babble*
Early
Average
Late
Use single words*
Early
Average
Late
Combine 2 words*
Early
Average
Late
Use phrases*
Early
Average
Late
Use sentences*
Early
Average
Late
Ask questions*
Early
Average
Late
Engage in Conversation*
Early
Average
Late

Describe your child as a baby (fussy, happy, easy or difficult to sooth, cried a lot, alert, cuddly, sociable, lethargic, etc.).

Communication Development

When you talk to your child, how much do you feel is understood?*
How does your child communicate wants and needs? Check all that apply. *
cries
points
signs
pulls toward object
gestures
vocalizes sounds
uses single words
uses many words, but only one at a time
uses phrases
uses long sentences
Does your child answer when you call?*
No
Yes
Does your child answer yes/no and wh- questions?*
No
Yes
Does your child ask for help?*
No
Yes
Does your child talk about what he/she is doing?*
No
Yes
What percentage of your child's speech do you understand?*
No
Yes
Can people outside the family understand your child's speech?*
No
Yes
Does your child stutter or stammer?*
No
Yes

Did you ever notice a change in your child's behavior, language, or social skills? If so, please describe the change and when it occurred. *

How does your child gain attention? *

Does your child have any sensory difficulties (tactile, visual, auditory etc.)? If yes, please describe. *

Feeding (if applicable)


Was your child breastfed or bottle-fed?

Was your child weaned to bottles, cups, or both?

Does your child drink from bottles, sippy cups, straws, or open cups?

Does your child use utensils independently?

Was feeding your child ever difficult? If so, please explain.

Does your child have any difficulty sucking, chewing, or swallowing? Please describe.

Is your child a picky or fussy eater?
Does your child eat a variety of foods? Please check all that apply.
soft
chewy
crunchy
sticky
cold
fruits
sweet
pureed
meats
vegetables
spicy
hot
breads
sour
dairy

If your child does not eat a variety of foods, please describe current diet.

Present Concerns


Please describe your concerns regarding your child's speech, language, feeding, play, and/or social development. *
Is your child aware of the problem?*
No
Yes

When did you first notice the difficulty? *

Has the problem changed since you first noticed? *
Does your child's communication difficulty cause frustration?*
No
Yes

Has your child ever been evaluated for therapeutic services? If yes, when and what were the recommended services? *

Has your child ever received any therapeutic interventions? If yes, please indicate which type (SP, OT, PT, EI, ABA etc.), when services began, and with whom. *
Does your child currently attend school or group activities?*
No
Yes

How do his/her peers and teachers react to the communication difficulty?

Any additional comments or questions?
Fourth Patient Name

First Name*

Last Name*
Fourth Patient Date of Birth*
Fourth Patient Case History and Background Information

Family History


Language(s) spoken in the home: *

Child's primary caregiver(s):

Parent's Full Name: *

Date of Birth:

Occupation:

E-mail address: *

Primary phone: *

Secondary phone:

Significant Medical history:

Parent's Full Name:

Date of Birth:

Occupation:

E-mail address:

Primary phone:

Secondary phone:

Significant Medical history:

Siblings: Name / Date of Birth / School and grade


1.

2.

3.

Is there any family history of difficulties similar to those your child is experiencing? Is there any family history of language, learning or developmental delays? If so, please describe. *

Pregnancy and Delivery


Mother's age at time of pregnancy:

Mother's general health during pregnancy:
Any difficulties with the pregnancy?*
No
Yes

If yes, please describe.

Please list any drugs or medications taken during pregnancy. *

Duration of pregnancy in weeks: *
Type of Labor:*

Duration:
Type of delivery:*

Other:

Please describe any labor and delivery complications. *

Birth weight: *

Apgar score:

Child's health post delivery:
Did baby accompany mother home from the hospital?*
No
Yes

If no, please explain.

Mother's health post delivery:

Medical History

If your child's medical history includes any of the following, please report the child's age at occurrence, number of occurrences and any other pertinent information.

Check all that apply
Accidents
Allergies
Asthma
Childhood diseases
Colds (persistent)
Colic
Ear infections
Eye infections
High fevers (persistent)
Hospitalizations
Operations
Seizures
Sinusitis
Throat infections
Tonsillitis
Other

If any checked, please provide additional information:

Medications your child takes regularly and what they are used for: *

Has your child's hearing been tested? If yes, when and what were the results. *

How many ear infections has your child suffered? *
Does your child hear you when his/her back is turned?*
No
Yes
Does your child hear you from another room?*
No
Yes
Does your child hear in a noisy environment?*
No
Yes

Developmental History

At approximately what age did your child do the following?

Early / Average / Late

Sit*
Early
Average
Late
Crawl*
Early
Average
Late
Walk*
Early
Average
Late
Babble*
Early
Average
Late
Use single words*
Early
Average
Late
Combine 2 words*
Early
Average
Late
Use phrases*
Early
Average
Late
Use sentences*
Early
Average
Late
Ask questions*
Early
Average
Late
Engage in Conversation*
Early
Average
Late

Describe your child as a baby (fussy, happy, easy or difficult to sooth, cried a lot, alert, cuddly, sociable, lethargic, etc.).

Communication Development

When you talk to your child, how much do you feel is understood?*
How does your child communicate wants and needs? Check all that apply. *
cries
points
signs
pulls toward object
gestures
vocalizes sounds
uses single words
uses many words, but only one at a time
uses phrases
uses long sentences
Does your child answer when you call?*
No
Yes
Does your child answer yes/no and wh- questions?*
No
Yes
Does your child ask for help?*
No
Yes
Does your child talk about what he/she is doing?*
No
Yes
What percentage of your child's speech do you understand?*
No
Yes
Can people outside the family understand your child's speech?*
No
Yes
Does your child stutter or stammer?*
No
Yes

Did you ever notice a change in your child's behavior, language, or social skills? If so, please describe the change and when it occurred. *

How does your child gain attention? *

Does your child have any sensory difficulties (tactile, visual, auditory etc.)? If yes, please describe. *

Feeding (if applicable)


Was your child breastfed or bottle-fed?

Was your child weaned to bottles, cups, or both?

Does your child drink from bottles, sippy cups, straws, or open cups?

Does your child use utensils independently?

Was feeding your child ever difficult? If so, please explain.

Does your child have any difficulty sucking, chewing, or swallowing? Please describe.

Is your child a picky or fussy eater?
Does your child eat a variety of foods? Please check all that apply.
soft
chewy
crunchy
sticky
cold
fruits
sweet
pureed
meats
vegetables
spicy
hot
breads
sour
dairy

If your child does not eat a variety of foods, please describe current diet.

Present Concerns


Please describe your concerns regarding your child's speech, language, feeding, play, and/or social development. *
Is your child aware of the problem?*
No
Yes

When did you first notice the difficulty? *

Has the problem changed since you first noticed? *
Does your child's communication difficulty cause frustration?*
No
Yes

Has your child ever been evaluated for therapeutic services? If yes, when and what were the recommended services? *

Has your child ever received any therapeutic interventions? If yes, please indicate which type (SP, OT, PT, EI, ABA etc.), when services began, and with whom. *
Does your child currently attend school or group activities?*
No
Yes

How do his/her peers and teachers react to the communication difficulty?

Any additional comments or questions?
Fifth Patient Name

First Name*

Last Name*
Fifth Patient Date of Birth*
Fifth Patient Case History and Background Information

Family History


Language(s) spoken in the home: *

Child's primary caregiver(s):

Parent's Full Name: *

Date of Birth:

Occupation:

E-mail address: *

Primary phone: *

Secondary phone:

Significant Medical history:

Parent's Full Name:

Date of Birth:

Occupation:

E-mail address:

Primary phone:

Secondary phone:

Significant Medical history:

Siblings: Name / Date of Birth / School and grade


1.

2.

3.

Is there any family history of difficulties similar to those your child is experiencing? Is there any family history of language, learning or developmental delays? If so, please describe. *

Pregnancy and Delivery


Mother's age at time of pregnancy:

Mother's general health during pregnancy:
Any difficulties with the pregnancy?*
No
Yes

If yes, please describe.

Please list any drugs or medications taken during pregnancy. *

Duration of pregnancy in weeks: *
Type of Labor:*

Duration:
Type of delivery:*

Other:

Please describe any labor and delivery complications. *

Birth weight: *

Apgar score:

Child's health post delivery:
Did baby accompany mother home from the hospital?*
No
Yes

If no, please explain.

Mother's health post delivery:

Medical History

If your child's medical history includes any of the following, please report the child's age at occurrence, number of occurrences and any other pertinent information.

Check all that apply
Accidents
Allergies
Asthma
Childhood diseases
Colds (persistent)
Colic
Ear infections
Eye infections
High fevers (persistent)
Hospitalizations
Operations
Seizures
Sinusitis
Throat infections
Tonsillitis
Other

If any checked, please provide additional information:

Medications your child takes regularly and what they are used for: *

Has your child's hearing been tested? If yes, when and what were the results. *

How many ear infections has your child suffered? *
Does your child hear you when his/her back is turned?*
No
Yes
Does your child hear you from another room?*
No
Yes
Does your child hear in a noisy environment?*
No
Yes

Developmental History

At approximately what age did your child do the following?

Early / Average / Late

Sit*
Early
Average
Late
Crawl*
Early
Average
Late
Walk*
Early
Average
Late
Babble*
Early
Average
Late
Use single words*
Early
Average
Late
Combine 2 words*
Early
Average
Late
Use phrases*
Early
Average
Late
Use sentences*
Early
Average
Late
Ask questions*
Early
Average
Late
Engage in Conversation*
Early
Average
Late

Describe your child as a baby (fussy, happy, easy or difficult to sooth, cried a lot, alert, cuddly, sociable, lethargic, etc.).

Communication Development

When you talk to your child, how much do you feel is understood?*
How does your child communicate wants and needs? Check all that apply. *
cries
points
signs
pulls toward object
gestures
vocalizes sounds
uses single words
uses many words, but only one at a time
uses phrases
uses long sentences
Does your child answer when you call?*
No
Yes
Does your child answer yes/no and wh- questions?*
No
Yes
Does your child ask for help?*
No
Yes
Does your child talk about what he/she is doing?*
No
Yes
What percentage of your child's speech do you understand?*
No
Yes
Can people outside the family understand your child's speech?*
No
Yes
Does your child stutter or stammer?*
No
Yes

Did you ever notice a change in your child's behavior, language, or social skills? If so, please describe the change and when it occurred. *

How does your child gain attention? *

Does your child have any sensory difficulties (tactile, visual, auditory etc.)? If yes, please describe. *

Feeding (if applicable)


Was your child breastfed or bottle-fed?

Was your child weaned to bottles, cups, or both?

Does your child drink from bottles, sippy cups, straws, or open cups?

Does your child use utensils independently?

Was feeding your child ever difficult? If so, please explain.

Does your child have any difficulty sucking, chewing, or swallowing? Please describe.

Is your child a picky or fussy eater?
Does your child eat a variety of foods? Please check all that apply.
soft
chewy
crunchy
sticky
cold
fruits
sweet
pureed
meats
vegetables
spicy
hot
breads
sour
dairy

If your child does not eat a variety of foods, please describe current diet.

Present Concerns


Please describe your concerns regarding your child's speech, language, feeding, play, and/or social development. *
Is your child aware of the problem?*
No
Yes

When did you first notice the difficulty? *

Has the problem changed since you first noticed? *
Does your child's communication difficulty cause frustration?*
No
Yes

Has your child ever been evaluated for therapeutic services? If yes, when and what were the recommended services? *

Has your child ever received any therapeutic interventions? If yes, please indicate which type (SP, OT, PT, EI, ABA etc.), when services began, and with whom. *
Does your child currently attend school or group activities?*
No
Yes

How do his/her peers and teachers react to the communication difficulty?

Any additional comments or questions?
Sixth Patient Name

First Name*

Last Name*
Sixth Patient Date of Birth*
Sixth Patient Case History and Background Information

Family History


Language(s) spoken in the home: *

Child's primary caregiver(s):

Parent's Full Name: *

Date of Birth:

Occupation:

E-mail address: *

Primary phone: *

Secondary phone:

Significant Medical history:

Parent's Full Name:

Date of Birth:

Occupation:

E-mail address:

Primary phone:

Secondary phone:

Significant Medical history:

Siblings: Name / Date of Birth / School and grade


1.

2.

3.

Is there any family history of difficulties similar to those your child is experiencing? Is there any family history of language, learning or developmental delays? If so, please describe. *

Pregnancy and Delivery


Mother's age at time of pregnancy:

Mother's general health during pregnancy:
Any difficulties with the pregnancy?*
No
Yes

If yes, please describe.

Please list any drugs or medications taken during pregnancy. *

Duration of pregnancy in weeks: *
Type of Labor:*

Duration:
Type of delivery:*

Other:

Please describe any labor and delivery complications. *

Birth weight: *

Apgar score:

Child's health post delivery:
Did baby accompany mother home from the hospital?*
No
Yes

If no, please explain.

Mother's health post delivery:

Medical History

If your child's medical history includes any of the following, please report the child's age at occurrence, number of occurrences and any other pertinent information.

Check all that apply
Accidents
Allergies
Asthma
Childhood diseases
Colds (persistent)
Colic
Ear infections
Eye infections
High fevers (persistent)
Hospitalizations
Operations
Seizures
Sinusitis
Throat infections
Tonsillitis
Other

If any checked, please provide additional information:

Medications your child takes regularly and what they are used for: *

Has your child's hearing been tested? If yes, when and what were the results. *

How many ear infections has your child suffered? *
Does your child hear you when his/her back is turned?*
No
Yes
Does your child hear you from another room?*
No
Yes
Does your child hear in a noisy environment?*
No
Yes

Developmental History

At approximately what age did your child do the following?

Early / Average / Late

Sit*
Early
Average
Late
Crawl*
Early
Average
Late
Walk*
Early
Average
Late
Babble*
Early
Average
Late
Use single words*
Early
Average
Late
Combine 2 words*
Early
Average
Late
Use phrases*
Early
Average
Late
Use sentences*
Early
Average
Late
Ask questions*
Early
Average
Late
Engage in Conversation*
Early
Average
Late

Describe your child as a baby (fussy, happy, easy or difficult to sooth, cried a lot, alert, cuddly, sociable, lethargic, etc.).

Communication Development

When you talk to your child, how much do you feel is understood?*
How does your child communicate wants and needs? Check all that apply. *
cries
points
signs
pulls toward object
gestures
vocalizes sounds
uses single words
uses many words, but only one at a time
uses phrases
uses long sentences
Does your child answer when you call?*
No
Yes
Does your child answer yes/no and wh- questions?*
No
Yes
Does your child ask for help?*
No
Yes
Does your child talk about what he/she is doing?*
No
Yes
What percentage of your child's speech do you understand?*
No
Yes
Can people outside the family understand your child's speech?*
No
Yes
Does your child stutter or stammer?*
No
Yes

Did you ever notice a change in your child's behavior, language, or social skills? If so, please describe the change and when it occurred. *

How does your child gain attention? *

Does your child have any sensory difficulties (tactile, visual, auditory etc.)? If yes, please describe. *

Feeding (if applicable)


Was your child breastfed or bottle-fed?

Was your child weaned to bottles, cups, or both?

Does your child drink from bottles, sippy cups, straws, or open cups?

Does your child use utensils independently?

Was feeding your child ever difficult? If so, please explain.

Does your child have any difficulty sucking, chewing, or swallowing? Please describe.

Is your child a picky or fussy eater?
Does your child eat a variety of foods? Please check all that apply.
soft
chewy
crunchy
sticky
cold
fruits
sweet
pureed
meats
vegetables
spicy
hot
breads
sour
dairy

If your child does not eat a variety of foods, please describe current diet.

Present Concerns


Please describe your concerns regarding your child's speech, language, feeding, play, and/or social development. *
Is your child aware of the problem?*
No
Yes

When did you first notice the difficulty? *

Has the problem changed since you first noticed? *
Does your child's communication difficulty cause frustration?*
No
Yes

Has your child ever been evaluated for therapeutic services? If yes, when and what were the recommended services? *

Has your child ever received any therapeutic interventions? If yes, please indicate which type (SP, OT, PT, EI, ABA etc.), when services began, and with whom. *
Does your child currently attend school or group activities?*
No
Yes

How do his/her peers and teachers react to the communication difficulty?

Any additional comments or questions?
Seventh Patient Name

First Name*

Last Name*
Seventh Patient Date of Birth*
Seventh Patient Case History and Background Information

Family History


Language(s) spoken in the home: *

Child's primary caregiver(s):

Parent's Full Name: *

Date of Birth:

Occupation:

E-mail address: *

Primary phone: *

Secondary phone:

Significant Medical history:

Parent's Full Name:

Date of Birth:

Occupation:

E-mail address:

Primary phone:

Secondary phone:

Significant Medical history:

Siblings: Name / Date of Birth / School and grade


1.

2.

3.

Is there any family history of difficulties similar to those your child is experiencing? Is there any family history of language, learning or developmental delays? If so, please describe. *

Pregnancy and Delivery


Mother's age at time of pregnancy:

Mother's general health during pregnancy:
Any difficulties with the pregnancy?*
No
Yes

If yes, please describe.

Please list any drugs or medications taken during pregnancy. *

Duration of pregnancy in weeks: *
Type of Labor:*

Duration:
Type of delivery:*

Other:

Please describe any labor and delivery complications. *

Birth weight: *

Apgar score:

Child's health post delivery:
Did baby accompany mother home from the hospital?*
No
Yes

If no, please explain.

Mother's health post delivery:

Medical History

If your child's medical history includes any of the following, please report the child's age at occurrence, number of occurrences and any other pertinent information.

Check all that apply
Accidents
Allergies
Asthma
Childhood diseases
Colds (persistent)
Colic
Ear infections
Eye infections
High fevers (persistent)
Hospitalizations
Operations
Seizures
Sinusitis
Throat infections
Tonsillitis
Other

If any checked, please provide additional information:

Medications your child takes regularly and what they are used for: *

Has your child's hearing been tested? If yes, when and what were the results. *

How many ear infections has your child suffered? *
Does your child hear you when his/her back is turned?*
No
Yes
Does your child hear you from another room?*
No
Yes
Does your child hear in a noisy environment?*
No
Yes

Developmental History

At approximately what age did your child do the following?

Early / Average / Late

Sit*
Early
Average
Late
Crawl*
Early
Average
Late
Walk*
Early
Average
Late
Babble*
Early
Average
Late
Use single words*
Early
Average
Late
Combine 2 words*
Early
Average
Late
Use phrases*
Early
Average
Late
Use sentences*
Early
Average
Late
Ask questions*
Early
Average
Late
Engage in Conversation*
Early
Average
Late

Describe your child as a baby (fussy, happy, easy or difficult to sooth, cried a lot, alert, cuddly, sociable, lethargic, etc.).

Communication Development

When you talk to your child, how much do you feel is understood?*
How does your child communicate wants and needs? Check all that apply. *
cries
points
signs
pulls toward object
gestures
vocalizes sounds
uses single words
uses many words, but only one at a time
uses phrases
uses long sentences
Does your child answer when you call?*
No
Yes
Does your child answer yes/no and wh- questions?*
No
Yes
Does your child ask for help?*
No
Yes
Does your child talk about what he/she is doing?*
No
Yes
What percentage of your child's speech do you understand?*
No
Yes
Can people outside the family understand your child's speech?*
No
Yes
Does your child stutter or stammer?*
No
Yes

Did you ever notice a change in your child's behavior, language, or social skills? If so, please describe the change and when it occurred. *

How does your child gain attention? *

Does your child have any sensory difficulties (tactile, visual, auditory etc.)? If yes, please describe. *

Feeding (if applicable)


Was your child breastfed or bottle-fed?

Was your child weaned to bottles, cups, or both?

Does your child drink from bottles, sippy cups, straws, or open cups?

Does your child use utensils independently?

Was feeding your child ever difficult? If so, please explain.

Does your child have any difficulty sucking, chewing, or swallowing? Please describe.

Is your child a picky or fussy eater?
Does your child eat a variety of foods? Please check all that apply.
soft
chewy
crunchy
sticky
cold
fruits
sweet
pureed
meats
vegetables
spicy
hot
breads
sour
dairy

If your child does not eat a variety of foods, please describe current diet.

Present Concerns


Please describe your concerns regarding your child's speech, language, feeding, play, and/or social development. *
Is your child aware of the problem?*
No
Yes

When did you first notice the difficulty? *

Has the problem changed since you first noticed? *
Does your child's communication difficulty cause frustration?*
No
Yes

Has your child ever been evaluated for therapeutic services? If yes, when and what were the recommended services? *

Has your child ever received any therapeutic interventions? If yes, please indicate which type (SP, OT, PT, EI, ABA etc.), when services began, and with whom. *
Does your child currently attend school or group activities?*
No
Yes

How do his/her peers and teachers react to the communication difficulty?

Any additional comments or questions?
Eighth Patient Name

First Name*

Last Name*
Eighth Patient Date of Birth*
Eighth Patient Case History and Background Information

Family History


Language(s) spoken in the home: *

Child's primary caregiver(s):

Parent's Full Name: *

Date of Birth:

Occupation:

E-mail address: *

Primary phone: *

Secondary phone:

Significant Medical history:

Parent's Full Name:

Date of Birth:

Occupation:

E-mail address:

Primary phone:

Secondary phone:

Significant Medical history:

Siblings: Name / Date of Birth / School and grade


1.

2.

3.

Is there any family history of difficulties similar to those your child is experiencing? Is there any family history of language, learning or developmental delays? If so, please describe. *

Pregnancy and Delivery


Mother's age at time of pregnancy:

Mother's general health during pregnancy:
Any difficulties with the pregnancy?*
No
Yes

If yes, please describe.

Please list any drugs or medications taken during pregnancy. *

Duration of pregnancy in weeks: *
Type of Labor:*

Duration:
Type of delivery:*

Other:

Please describe any labor and delivery complications. *

Birth weight: *

Apgar score:

Child's health post delivery:
Did baby accompany mother home from the hospital?*
No
Yes

If no, please explain.

Mother's health post delivery:

Medical History

If your child's medical history includes any of the following, please report the child's age at occurrence, number of occurrences and any other pertinent information.

Check all that apply
Accidents
Allergies
Asthma
Childhood diseases
Colds (persistent)
Colic
Ear infections
Eye infections
High fevers (persistent)
Hospitalizations
Operations
Seizures
Sinusitis
Throat infections
Tonsillitis
Other

If any checked, please provide additional information:

Medications your child takes regularly and what they are used for: *

Has your child's hearing been tested? If yes, when and what were the results. *

How many ear infections has your child suffered? *
Does your child hear you when his/her back is turned?*
No
Yes
Does your child hear you from another room?*
No
Yes
Does your child hear in a noisy environment?*
No
Yes

Developmental History

At approximately what age did your child do the following?

Early / Average / Late

Sit*
Early
Average
Late
Crawl*
Early
Average
Late
Walk*
Early
Average
Late
Babble*
Early
Average
Late
Use single words*
Early
Average
Late
Combine 2 words*
Early
Average
Late
Use phrases*
Early
Average
Late
Use sentences*
Early
Average
Late
Ask questions*
Early
Average
Late
Engage in Conversation*
Early
Average
Late

Describe your child as a baby (fussy, happy, easy or difficult to sooth, cried a lot, alert, cuddly, sociable, lethargic, etc.).

Communication Development

When you talk to your child, how much do you feel is understood?*
How does your child communicate wants and needs? Check all that apply. *
cries
points
signs
pulls toward object
gestures
vocalizes sounds
uses single words
uses many words, but only one at a time
uses phrases
uses long sentences
Does your child answer when you call?*
No
Yes
Does your child answer yes/no and wh- questions?*
No
Yes
Does your child ask for help?*
No
Yes
Does your child talk about what he/she is doing?*
No
Yes
What percentage of your child's speech do you understand?*
No
Yes
Can people outside the family understand your child's speech?*
No
Yes
Does your child stutter or stammer?*
No
Yes

Did you ever notice a change in your child's behavior, language, or social skills? If so, please describe the change and when it occurred. *

How does your child gain attention? *

Does your child have any sensory difficulties (tactile, visual, auditory etc.)? If yes, please describe. *

Feeding (if applicable)


Was your child breastfed or bottle-fed?

Was your child weaned to bottles, cups, or both?

Does your child drink from bottles, sippy cups, straws, or open cups?

Does your child use utensils independently?

Was feeding your child ever difficult? If so, please explain.

Does your child have any difficulty sucking, chewing, or swallowing? Please describe.

Is your child a picky or fussy eater?
Does your child eat a variety of foods? Please check all that apply.
soft
chewy
crunchy
sticky
cold
fruits
sweet
pureed
meats
vegetables
spicy
hot
breads
sour
dairy

If your child does not eat a variety of foods, please describe current diet.

Present Concerns


Please describe your concerns regarding your child's speech, language, feeding, play, and/or social development. *
Is your child aware of the problem?*
No
Yes

When did you first notice the difficulty? *

Has the problem changed since you first noticed? *
Does your child's communication difficulty cause frustration?*
No
Yes

Has your child ever been evaluated for therapeutic services? If yes, when and what were the recommended services? *

Has your child ever received any therapeutic interventions? If yes, please indicate which type (SP, OT, PT, EI, ABA etc.), when services began, and with whom. *
Does your child currently attend school or group activities?*
No
Yes

How do his/her peers and teachers react to the communication difficulty?

Any additional comments or questions?
Ninth Patient Name

First Name*

Last Name*
Ninth Patient Date of Birth*
Ninth Patient Case History and Background Information

Family History


Language(s) spoken in the home: *

Child's primary caregiver(s):

Parent's Full Name: *

Date of Birth:

Occupation:

E-mail address: *

Primary phone: *

Secondary phone:

Significant Medical history:

Parent's Full Name:

Date of Birth:

Occupation:

E-mail address:

Primary phone:

Secondary phone:

Significant Medical history:

Siblings: Name / Date of Birth / School and grade


1.

2.

3.

Is there any family history of difficulties similar to those your child is experiencing? Is there any family history of language, learning or developmental delays? If so, please describe. *

Pregnancy and Delivery


Mother's age at time of pregnancy:

Mother's general health during pregnancy:
Any difficulties with the pregnancy?*
No
Yes

If yes, please describe.

Please list any drugs or medications taken during pregnancy. *

Duration of pregnancy in weeks: *
Type of Labor:*

Duration:
Type of delivery:*

Other:

Please describe any labor and delivery complications. *

Birth weight: *

Apgar score:

Child's health post delivery:
Did baby accompany mother home from the hospital?*
No
Yes

If no, please explain.

Mother's health post delivery:

Medical History

If your child's medical history includes any of the following, please report the child's age at occurrence, number of occurrences and any other pertinent information.

Check all that apply
Accidents
Allergies
Asthma
Childhood diseases
Colds (persistent)
Colic
Ear infections
Eye infections
High fevers (persistent)
Hospitalizations
Operations
Seizures
Sinusitis
Throat infections
Tonsillitis
Other

If any checked, please provide additional information:

Medications your child takes regularly and what they are used for: *

Has your child's hearing been tested? If yes, when and what were the results. *

How many ear infections has your child suffered? *
Does your child hear you when his/her back is turned?*
No
Yes
Does your child hear you from another room?*
No
Yes
Does your child hear in a noisy environment?*
No
Yes

Developmental History

At approximately what age did your child do the following?

Early / Average / Late

Sit*
Early
Average
Late
Crawl*
Early
Average
Late
Walk*
Early
Average
Late
Babble*
Early
Average
Late
Use single words*
Early
Average
Late
Combine 2 words*
Early
Average
Late
Use phrases*
Early
Average
Late
Use sentences*
Early
Average
Late
Ask questions*
Early
Average
Late
Engage in Conversation*
Early
Average
Late

Describe your child as a baby (fussy, happy, easy or difficult to sooth, cried a lot, alert, cuddly, sociable, lethargic, etc.).

Communication Development

When you talk to your child, how much do you feel is understood?*
How does your child communicate wants and needs? Check all that apply. *
cries
points
signs
pulls toward object
gestures
vocalizes sounds
uses single words
uses many words, but only one at a time
uses phrases
uses long sentences
Does your child answer when you call?*
No
Yes
Does your child answer yes/no and wh- questions?*
No
Yes
Does your child ask for help?*
No
Yes
Does your child talk about what he/she is doing?*
No
Yes
What percentage of your child's speech do you understand?*
No
Yes
Can people outside the family understand your child's speech?*
No
Yes
Does your child stutter or stammer?*
No
Yes

Did you ever notice a change in your child's behavior, language, or social skills? If so, please describe the change and when it occurred. *

How does your child gain attention? *

Does your child have any sensory difficulties (tactile, visual, auditory etc.)? If yes, please describe. *

Feeding (if applicable)


Was your child breastfed or bottle-fed?

Was your child weaned to bottles, cups, or both?

Does your child drink from bottles, sippy cups, straws, or open cups?

Does your child use utensils independently?

Was feeding your child ever difficult? If so, please explain.

Does your child have any difficulty sucking, chewing, or swallowing? Please describe.

Is your child a picky or fussy eater?
Does your child eat a variety of foods? Please check all that apply.
soft
chewy
crunchy
sticky
cold
fruits
sweet
pureed
meats
vegetables
spicy
hot
breads
sour
dairy

If your child does not eat a variety of foods, please describe current diet.

Present Concerns


Please describe your concerns regarding your child's speech, language, feeding, play, and/or social development. *
Is your child aware of the problem?*
No
Yes

When did you first notice the difficulty? *

Has the problem changed since you first noticed? *
Does your child's communication difficulty cause frustration?*
No
Yes

Has your child ever been evaluated for therapeutic services? If yes, when and what were the recommended services? *

Has your child ever received any therapeutic interventions? If yes, please indicate which type (SP, OT, PT, EI, ABA etc.), when services began, and with whom. *
Does your child currently attend school or group activities?*
No
Yes

How do his/her peers and teachers react to the communication difficulty?

Any additional comments or questions?
Tenth Patient Name

First Name*

Last Name*
Tenth Patient Date of Birth*
Tenth Patient Case History and Background Information

Family History


Language(s) spoken in the home: *

Child's primary caregiver(s):

Parent's Full Name: *

Date of Birth:

Occupation:

E-mail address: *

Primary phone: *

Secondary phone:

Significant Medical history:

Parent's Full Name:

Date of Birth:

Occupation:

E-mail address:

Primary phone:

Secondary phone:

Significant Medical history:

Siblings: Name / Date of Birth / School and grade


1.

2.

3.

Is there any family history of difficulties similar to those your child is experiencing? Is there any family history of language, learning or developmental delays? If so, please describe. *

Pregnancy and Delivery


Mother's age at time of pregnancy:

Mother's general health during pregnancy:
Any difficulties with the pregnancy?*
No
Yes

If yes, please describe.

Please list any drugs or medications taken during pregnancy. *

Duration of pregnancy in weeks: *
Type of Labor:*

Duration:
Type of delivery:*

Other:

Please describe any labor and delivery complications. *

Birth weight: *

Apgar score:

Child's health post delivery:
Did baby accompany mother home from the hospital?*
No
Yes

If no, please explain.

Mother's health post delivery:

Medical History

If your child's medical history includes any of the following, please report the child's age at occurrence, number of occurrences and any other pertinent information.

Check all that apply
Accidents
Allergies
Asthma
Childhood diseases
Colds (persistent)
Colic
Ear infections
Eye infections
High fevers (persistent)
Hospitalizations
Operations
Seizures
Sinusitis
Throat infections
Tonsillitis
Other

If any checked, please provide additional information:

Medications your child takes regularly and what they are used for: *

Has your child's hearing been tested? If yes, when and what were the results. *

How many ear infections has your child suffered? *
Does your child hear you when his/her back is turned?*
No
Yes
Does your child hear you from another room?*
No
Yes
Does your child hear in a noisy environment?*
No
Yes

Developmental History

At approximately what age did your child do the following?

Early / Average / Late

Sit*
Early
Average
Late
Crawl*
Early
Average
Late
Walk*
Early
Average
Late
Babble*
Early
Average
Late
Use single words*
Early
Average
Late
Combine 2 words*
Early
Average
Late
Use phrases*
Early
Average
Late
Use sentences*
Early
Average
Late
Ask questions*
Early
Average
Late
Engage in Conversation*
Early
Average
Late

Describe your child as a baby (fussy, happy, easy or difficult to sooth, cried a lot, alert, cuddly, sociable, lethargic, etc.).

Communication Development

When you talk to your child, how much do you feel is understood?*
How does your child communicate wants and needs? Check all that apply. *
cries
points
signs
pulls toward object
gestures
vocalizes sounds
uses single words
uses many words, but only one at a time
uses phrases
uses long sentences
Does your child answer when you call?*
No
Yes
Does your child answer yes/no and wh- questions?*
No
Yes
Does your child ask for help?*
No
Yes
Does your child talk about what he/she is doing?*
No
Yes
What percentage of your child's speech do you understand?*
No
Yes
Can people outside the family understand your child's speech?*
No
Yes
Does your child stutter or stammer?*
No
Yes

Did you ever notice a change in your child's behavior, language, or social skills? If so, please describe the change and when it occurred. *

How does your child gain attention? *

Does your child have any sensory difficulties (tactile, visual, auditory etc.)? If yes, please describe. *

Feeding (if applicable)


Was your child breastfed or bottle-fed?

Was your child weaned to bottles, cups, or both?

Does your child drink from bottles, sippy cups, straws, or open cups?

Does your child use utensils independently?

Was feeding your child ever difficult? If so, please explain.

Does your child have any difficulty sucking, chewing, or swallowing? Please describe.

Is your child a picky or fussy eater?
Does your child eat a variety of foods? Please check all that apply.
soft
chewy
crunchy
sticky
cold
fruits
sweet
pureed
meats
vegetables
spicy
hot
breads
sour
dairy

If your child does not eat a variety of foods, please describe current diet.

Present Concerns


Please describe your concerns regarding your child's speech, language, feeding, play, and/or social development. *
Is your child aware of the problem?*
No
Yes

When did you first notice the difficulty? *

Has the problem changed since you first noticed? *
Does your child's communication difficulty cause frustration?*
No
Yes

Has your child ever been evaluated for therapeutic services? If yes, when and what were the recommended services? *

Has your child ever received any therapeutic interventions? If yes, please indicate which type (SP, OT, PT, EI, ABA etc.), when services began, and with whom. *
Does your child currently attend school or group activities?*
No
Yes

How do his/her peers and teachers react to the communication difficulty?

Any additional comments or questions?
Patient Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email
A signed copy of this waiver will be sent to the email address you provide.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*