Patient Information & Child History Form
Responsible Party

Name
Insurance Information

Child History Form
The following information is for professional use and will be handled confidentially. This information will assist the therapists in completing your child’s evaluation.
General Information

Developmental/ Medical History
Prenatal and Birth History
Does your child have or has had any of the following conditions

If you have copies of these evaluations and services, please bring them to the evaluation.

Speech and Language History
When did your child first do the following
Play Preferences

Behavior

Parent or Caregiver’s Statement of the Problem