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THERAPY SPOT CHILD HISTORY FORM
FORM NAME
DESCRIPTION
BIOGRAPHICAL INFORMATION
First name of child
Last name of child
*
Date of Birth (DD/MM/YYYY)
*
Parent Name
*
Cell Phone
*
Email of parent
*
Other Parent/Guardian Name
*
Cell phone of other Parent/Guardian
*
email of other Parent/Guardian
*
What is your Address
*
What is your Address
What is your Address
What is your Address
City
City
State/Province
State/Province
Zip/Postal
Zip/Postal
Country
Afghanistan
Aland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei
Bulgaria
Burkina Faso
Burundi
Côte d'Ivoire
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten (Dutch part)
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Country
Do you have any funding?
OAP
No grants
TREATMENT GOALS
What are your concerns that bring you to the clinic?
*
Using words to talk
Managing behaviour
Eating
Being independent
Understanding language
Speech sounds
Learning
School Readiness
Toileting
Hearing
Difficulty playing with children their age Poor eye contact
Doesn't respond to their name
Plays with less than 3 toys
Doesn't point to what they want
Easily distracted
Difficulty making friends
Stuttering
Listening & Understanding
Writing
Reading
Organization
Of your above concerns, what is your TOP # 1 priority for the next 12 weeks?
What type of therapy are you interested in (check all that apply)
Speech Therapy (1 on 1)
BCBA 1 on 1
Instructor Therapist (1 on 1)
GABA Groups
BIRTH AND MEDICAL HISTORY
Was your child born full term? If not, please state gestational age.
Were there any complications during pregnancy or birth? If yes, please explain.
What was the method of delivery (e.g., vaginal, breech, cesarean)?
Is your child currently taking any medications? If yes, please list medication(s).
Has your child had any surgeries, accidents and/or significant illnesses? If yes, please explain.
Does your child have any known food allergies? If yes, are these allergies anaphylactic, and does your child carry an epipen with him/her? Please explain.
When was your child's most recent hearing and vision tests? Please provide date and results.
Has your child had any ear infections? If so, how many and what was the date of the last ear infection?
Does your child have a formal diagnosis?
*
ASD
ADHD
Sensory Processing Disorder
Apraxia of Speech
Articulation
Language Disorder
Learning Disability
Oral Myofunctional Disorder
Voice
Stuttering
Other
Other
If yes, what year were you diagnosed?
What is your family physician's name and phone number?
SOCIAL HISTORY
Who does your child live with? Please indicate any siblings, and siblings' ages.
Who does your child spend most of their time with? Please explain?
What languages are spoken in the home? What languages does your child speak?
*
Does your child attend daycare, preschool, elementary school, etc.? If yes, please state program/school, and grade, if applicable.
Does your child receive any special services within the school?
SPEECH AND LANGUAGE
Please describe your main concerns regarding your child's speech and language.
What is your child's primary mode of communication (gestures, signing, single words, phrases, full sentences, augmentative device etc)?
Are there any speech-language or hearing problems in your family? If so, please describe.
Has your child received speech-language services in the past? If yes, please indicate the name of clinician, the date and time span of therapy received.
How many words (approximately) does your child currently say?
< 5
<20
<100
more than 100
more than 1000
My child uses short phrases to speak
My child uses long phrases to speak
How much of your child's speech do you understand?
0-25%
25-50%
50-75%
75-100%
How much of child's speech does a stranger or unfamiliar listener understand?
0-25%
25-50%
50-75%
75-100%
Please indicate the approximate age your child began to: 1. Babble; 2. Say first words; 3. Combine 2-3 words together; 4. Speak in full sentences;
Does your child have more challenging behaviours than same aged peers?
Yes
no
If yes, please describe the behaviours you have observed.
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How did you hear about us?
Google
Professional referral
friend
OSLA
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