Case History Form

READY TO START YOUR CHILD’S

journey?

Fill out the intake form below.

If online forms aren’t your thing, no problem. Simply give us a call to book your first appointment then download and print the PDF below. Once you've filled it out you can either email it to us or bring it with you to your first appointment.

download pdf

To submit the intake form online, complete the questions first then give us a call to book your first appointment. The form will provide us with a brief history of your child and any communication challenges they are experiencing. We’ll take your personal contact details over the phone.

Child's Name*
First Name Last Name Initial
Does your child have a diagnosis? If yes, please list.
What concerns do you have about your child’s communication/feeding skills?
When did you first have these concerns?
What concerns do others have about your child’s communication/feeding skills?
What would you like to achieve from speech pathology sessions?
What languages are spoken at home?
Has your child ever received speech pathology services? If yes, where and when?
What are your child’s strengths and interests?
Has your child had their vision and hearing checked? If yes, where and when? What were the results?
Have any family members had any speech, language, hearing, or learning difficulties? If yes, who? Please describe:
Has your child had any surgery/hospitalisations? If yes, please describe.
Is your child taking any medications regularly? If yes, please list.
Tell me about your childs developmental milestones eg sitting, walking, first words, toilet training.
Does your child receive other services? (eg Physiotherapy, Psychology) If yes, please list.
I give permission for you to speak with the following people regarding my child: (eg Paediatrician, Teacher, Occupational Therapist)
CAPTCHA

10 simple ways to support your child’s communication skills

at home!

Simple strategies you can use in everyday interactions with your child to assist their speech and language development.

READY TO START YOUR CHILD’S

journey?

Case History Form

10 simple ways to support your child’s communication skills

at home!

Download now - it’s FREE!

Brighter Outcomes

Get In Touch

Where to find us

2/ 165 Commercial Street East,
Mount Gambier SA 5290

1A McRae Street,
Naracoorte SA
5271

Opening hours

READY TO START YOUR CHILD’S

journey?

Case History Form

10 simple ways to support your child’s communication skills

at home!

Download now - it’s FREE!

Brighter Outcomes

Get In Touch

Where to find us

2/ 165 Commercial Street East,Mount Gambier SA 5290

1A McRae Street,Naracoorte SA5271

Opening hours

2/ 165 Commercial Street East,
Mount Gambier SA 5290

1A McRae Street,
Naracoorte SA
5271