Client Information Profile

The information you provide will help the Speech-Language Pathologist gain a thorough understanding of your child and enable provision of the most appropriate service and management.

Identifying and Family Information
Child’s First Name*
Child’s Last Name*
Date of Birth*
MM slash DD slash YYYY
Current Age*
Sex
- M
- F
1. Parent/Guardian
First Name*
Last Name*
Relationship to child*
Residential address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone - Home
Phone - Mobile*
Phone - Work
Phone - Fax
Email*
Occupation
2. Parent/Guardian
Name*
Relationship to child*
Residential address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone - Home
Phone - Mobile*
Phone - Work
Phone - Fax
Email*
Occupation
Who is currently living at home with the child?*
Languages Spoken at home*
If there is a language other than English spoken in the home:
Does the child speak the language?
- Y
- N
Does the child understand the language?
- Y
- N
Who speaks the language?
Which language does the child prefer to speak at home?
Speech, Language, Learning and Hearing
What are your concerns about your child’s speech, language, learning and/or hearing?*
Do any family members (including aunties, uncles, grandparents, cousins, siblings, parents, etc) have a history of speech, language, learning or hearing difficulties? If so, please provide details:
Do you have any concerns about your child’s development/progress in any of the following areas? If yes, please describe your concerns.
speech (saying sounds) PLEASE PROVIDE EXAMPLES OF HOW YOUR CHILD SAYS AT LEAST THREE WORDS
language (using and understanding words and sentences) PLEASE PROVIDE EXAMPLES OF THREE SENTENCES YOUR CHILD SAYS
reading
spelling
math
voice quality
fluency (stuttering)
physical skills (gross and/or fine motor)
feeding/swallowing
hearing
memory
attention
behavior
social skills
Who first noticed your child’s speech, language learning and/or hearing difficulties?
When were your child’s speech, language learning and/or hearing difficulties first noticed?
Has your child ever received an evaluation or therapy from any other medical or allied health service specialist? If so, please specify and explain further below. Please include the name of the practitioner, the place & date and the outcome.
Paediatrician
Ear Nose & Throat Specialist
Audiologist
Speech-Language Pathologist
Psychologist
Counselor
Eye Specialist
Occupational Therapist
Physiotherapist
Other
**IF you have a report from any of these specialists, please provide a copy.
Birth History
Pregnancy was
- Premature
- Full term
- Overdue
Was there anything unusual or any complications during the pregnancy and/or during or after the birth of your child? If yes, please describe.
What was the general health of your baby in their first year?
Medical History
Has your child had any of the following? If so, please specify and explain further below. Please include when, how often (if applicable) and the outcome/management.
Tonsillitis
Tonsillectomy
Adenoidectomy
Ear infections
Frequent colds/flu
Ear tubes
Cleft lip and/or palate
Breathing difficulties
Mouth breathing
Asthma
Feeding difficulties (sucking; introduction to solids; chewing, other)
Sleeping difficulties
Vision Problems
Thumb/finger sucking habit
Encephalitis
Head injury
Epilepsy
Seizures
Any other pertinent injury, illness or surgery
Is your child currently taking any medications? If so, please provide details.
Developmental History
Please specify the approximate age your child achieved the following development milestones.
Sat alone
Babbled (e.g. ‘baba’, ‘gaga’)
Said first words
Walked
Put two words together
Educational History
Name of daycare, preschool, school
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email
Grade in school
Teachers name
Name of support teacher/assistant (if applicable)
Has your child ever repeated a grade? If so, please specify
What are your child’s strengths and best subjects?
Is your child having difficulty with any subjects? If so, please specify
Is your child receiving extra help in any subjects?
If you have recent school reports, please provide a copy of these.
General Behavior
Please tick as they apply to your child:
- Friendly
- Confident
- Easy-going
- Talkative
- Nervous
- Shy
- Anxious
- Quiet
Other:
Do any of the following apply to your child:
- Seems clumsy
- Walks in an awkward manner
- Frequently throws tantrums
- Aggressive and/or destructive
- Likes to follow a strict routine
- Resistant to contact
- Impulsive
- Has some separation anxiety
- Loses balance easily
- Repeatedly mimics what you say
- Withdraws from social interaction
- Displays some repetitive behavior
- Avoids making eye contact
- Easy to manage
- Inattentive
- Over-sensitive to sounds and/or surroundings
Other:
Does your child have any preferred games, toys or hobbies?
How does your child like to spend his/her play/free time?
Additional Comments/ Other relevant information
Is there any other information you would like to add that might assist us in working with your child?
Ongoing Availability
This assists us connecting you with a clinician who can match your schedule. Please list your availability using the following format: (e.g., Monday: 9:00 to 12:00, Tuesday: all day, Wednesday: 3:30 to 6:00, or n/a if this day doesn't work for your schedule.)
Monday*
Tuesday*
Wednesday*
Thursday*
Friday*
Saturday*
Sunday*
Additional Comments about Availability: (if you don't have a consistent schedule, and need to go week by week, please indicate so and some possible options for availability)
Service Delivery Preference*
- In-Person
- Teletherapy
- No preference
Name of extended health coverage and/or funding provider
Semiahmoo Speech Services Inc., has a 24 hour cancellation policy for all services. Once you have scheduled an appointment/s 24-hour cancellation notice is required, if notification is not received prior to 24 hours from the booked appointment, you will be billed for the session IN FULL. Please indicate you understand these conditions by printing your initials in the box*
Completed by
Date completed
MM slash DD slash YYYY
Location*
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Client Information Profile

Identifying and Family Information

1. Parent/Guardian

2. Parent/Guardian

Speech, Language, Learning and Hearing

Birth History

Medical History

Developmental History

Educational History

General Behavior

Additional Comments/ Other relevant information