Child Information Form

Client Agreement

  • Child Information
  • Birth and Family History
  • Education & Speech
  • Client Agreement

Child Details

First Name

Surname

Full Address

Postcode

Birth date

Sex

Parent / Caregiver 1 :

Name

Relationship to child

Contact number (in case of multiple numbers seperate by ' , ' comma)

Email

Occupation

Address (if different from child's)

Parent / Caregiver 2 :

Name

Relationship to Child

Contact number (in case of multiple numbers seperate by ' , ' comma)

Email

Occupation

Address (if different from child's)

Doctor :

Name

NHI Number

Medical Centre/GP Surgery

Specialist :

Name

How did you find Vocalsaints ?

Referral By

Please mention the name of the referral source selected above (if applicable)

Do you give us permission to speak with teachers regarding your child if necessary?

Child lives with :

Please mention the name and age of all the people that child lives with (as selected above) | example = Tom - 29

Is there a language other than English spoken in the home ?

If yes, which one(s) :

Does the child speak the language ?

Does the child understand the language ?

Who else speaks the language ?

Which language does the child prefer to speak at home ?

Do you consider your child to be bi/multi-lingual (i.e. learning and using more than one language) ?

Birth and Family History

Is there a family history ─ immediate or extended family ─ members of:

Speech delay or disorder

Language delay or disorder

Learning difficulties / Dyslexia

Intellectual impairment

Hearing impairment / grommets

Stutter

Medical diagnosis, e.g. Down Syndrome, Autism

How many weeks was the pregnancy ?

Child’s birth weight :

Medical History

Has your child had any of the following ?

Please describe other serious injury/surgery :

Please list any medications your child takes regularly :

School History

Name of school and year in school :

Teacher’s name :

Has she/he repeated a year ?

If yes, which year ?

What are his/her strengths and/or best subjects ?

is s/he having any difficulties with any subjects ?

If yes, which ?

Is your child receiving help in any subjects ?

If yes, which ?

Have any Teachers expressed concerned? If so, please describe

Child's Interest (What are his/her interests? What does s/he enjoy doing?)

What are things that particularly motivate your child ? (e.g. certain toys, activities, food)

Regular (weekly or fortnightly) opportunities include :

In case of other, Please mention :

Screen Time :

On average, how much time does your child spend each day on the following :

Computer (Hours, Minutes)

TV (Hours, Minutes)

ipad (Hours, Minutes)

Phone (Hours, Minutes)

Current favourite movies or shows :

Current Speech and Language

Speech sounds:

Does your child make a variety of different sounds ? (please tick the sounds your child makes on a regular basis)

If your child makes speech sound changes, do you think they are consistent ?

e.g. “cat is always “tat”, “gone” is always “don”) ?

If yes, please give an example(s) :

Does your child have a favourite sound, for example may attempt at different words that sound similar, such as “da”

Approximately how much can you understand your child in conversation: ______ regiver1 ______ regiver2. Please write respectively seperated by comma (',')

Time of sleep (on average)

Night time from ___ pm until ___ am. (example '9:00 pm to 6:00 am')

Day time from ___ until ___ . (example '3:30 pm to 6:00 pm')

Average number of hours sleep per 24 hour period :

Does your child snore?

Speech Language Therapy

What are your concerns about your child’s speech sounds and/or language skills ?

Please provide additional details (if any)

Has your child ever had speech therapy assessment appointment?

If yes, where and when ?

What were you told ?

Are you currently with or on the waitlist for the Ministry of Education or the Ministry of Health ?

Has your child ever had speech therapy lessons ?

If yes, when and where ? Please also describe what was worked on ?

Has your child ever had hearing test with an Audiologist ?

If yes, when and where ? | What were you told ? (Please describe)

Has your child ever had any other tests/screens for hearing loss or glue ear ?

Has your child ever seen an ENT specialist ?

If yes, please tell why ?

Do you have any concerns about your child’s hearing ?

Has s/he received any other assessment or therapy (e.g. from a physiotherapist, psychologist, occupational therapist, or SPELD) ?

If yes, please describe

Do you have concerns about any other areas of your child’s development, including their behaviour ?

Are you currently on a service waitlist? (E.g.: Audiology, ENT, Child Development services, MOE, MOH etc.)

Is your child aware of, or frustrated by his/her speech/language difficulties ?

What do you see as your child’s most difficult communication problem at home ?

What do you see as your child’s most difficult communication problem at school or centre ?

If You Are Concerned About Stuttering

If you are particularly concerned about a stutter :

Is there a known family history of stuttering ?

What age did you first start to notice a stutter ?

Please provide a description or example of the stutter: (E.g.: repetition of sounds and words, can’t get words out etc.)

Have you noticed any changes in the stutter since it started ?

If yes, please describe :

Is the stutter episodic (comes and goes) or continuous (present most of the time the child talks)?

Is your child aware of their stutter ?

What advice have you been given ?

If You Are Concerned About Voice Quality

If you are particulary concerned about your child’s voice quality :

Is there a known family history of voice difficulties ?

What age did you first start to notice a change in your child’s voice ?

What is the main concern about your child’s voice ?

How would you describe your child’s voice? (E.g.: Husky, croaky, monotone, crackly etc.)

Does your child get frequent sore throats ?

Appointments

What would you most like to achieve from your assessment appointment?

For example, the entry point to establish therapy goals, knowledge of child’s speech/language skills, guidance to support child’s communication development.

What would you most like your child to achieve from therapy?

For example: understandable speech to family and peers, language appropriate to aged peers, stimulation to develop language skills, reduction of stutter, whatever is idetnified as a need from speech-language assessment.

Often therapy involves building carer/parental knowledge as well as direct intevention with a child. Is there a parent/carer who can regularly attend therapy appointments?

Are you concerned about your child’s (speech/language) communication skills prior to starting school?

Your Availability

Days and times that would suit for therapy appointments:

  • Monday morning afternoon
  • Tuesday morning afternoon
  • Wednesday morning afternoon
  • Thursday morning afternoon
  • Friday morning afternoon
  • Saturday morning afternoon (please note that this day is only available in certain locations)

Do you have any current commitments or restraints that may impact on regular engagement in therapy? e.g: days/times of other appointments, finanical obligations etc.

Additional Comments

Please provide if any

Name of person who completed the form:

Date

Client Agreement and Consent notice

Name

Date of Birth

I agree (please tick each box):

Optional consent

I give consent for my child to:

Name:

Relationship to child:

Date