Client Contact Literacy

Today's Date*
Child's Name*
First Last
Child's Date of Birth*
Your Name*
First Last
Parent/Guardian/Carer
Address for correspondence*
Street Address Address Line 2 Suburb State Post Code Country
Email*
Mobile Phone*
Does your child have siblings? Please include name(s) and date(s) of birth:
Child's History
Does child attend child care, kindy, school?*
- Child Care
- Kindy
- Play Group
- School
- No
If yes please list location address and teacher name
Your Concerns - Please detail your reason for requesting appointment*
Medical History
Does the child have a formal diagnosis?*
If Yes, please detail full description below of date and diagnosis.
- Yes
- No
- In the process of seeking diagnosis
Date and description of formal diagnosis.
Does the child attend with other specialists & health professionals? Please detail, name, specialty, how long you have been attending with them.
Paediatrician, GP, Occupational Therapist, Psychologist, other Speech Language Pathologist?
Does the child take medication on a regular basis.
If Yes please list medication and it's purpose.
Has child's hearing been tested
- Yes
- No
If yes, please advise date hearing checked and result
Communication
Please detail child's general interests
Is English your child's primary language? If no, please specify other languages
Provide the approximate age your child began to use single words
Provide the approximate age your child began to combine words e.g. go out, want drink
Provide the approximate age your child began to engage in conversation
Does your child have difficulty walking, running, or doing activities that require small or large muscle coordination?*
Gesture, single words, short phrases, sentences, conversation?
Describe child's level of understanding*
Please give examples. Are you concerned with this?
Does child become frustrated when not able to communicate clearly?*
Is your child aware of any difficulties they are having? If yes, how do they feel about it?
Are there any other family members with speech, language, learning, reading, attention or hearing problems? If Yes please describe.
Does your child make friends easily*
- Yes
- No
- Not sure
Does your child have more success interacting with adults than their peers?*
- Yes
- No
- Not sure
How does your child interact with others? e.g.Shy, aggressive, inflexible? Please describe
Do you have any concerns about your child's social skills? Their ability to make and keep friends?
Education History
Did/does your child attend kindy?
If Yes, Please detail where, how many days full or half days a week.
Does your child sit through circle/mat time
Has your child's teacher reported any concerns to you? Please describe
Have you reported any concerns to your child's teacher.
How is your child doing academically (or pre academically)? Please comment on reading and written language.
Does your child like school?
- Yes
- No
Does your child enjoy reading
- Yes
- No
Does your child enjoy being read to?
- Yes
- No
Does your child have an Individual Education Plan or Educational Adjustment Plan? Please attach.
Please describe your Childs' educational setting
- Regular education
- Fully Mainstreamed
- Integrated (some time in special classes)
Learning Support - Please specify the type and frequency of support. e.g. reading group, teacher aide.
To assist the speech pathologist obtain a complete profile of your child's strength and weaknesses, please tick below all that apply.
Listening
- Has trouble paying attention
- Has trouble following spoken directions
- Has trouble remembering things people say
- Has trouble understanding what people say
- Has to ask people to repeat what they have said
- Has trouble understanding the meaning of words
- Has trouble understanding new ideas
- Has trouble looking at people when talking or listening
- Has trouble understanding facial expressions, gestures or body language
Attention
- Often fails to give close attention to detail or makes careless mistakes in school work or other activities
- Often has difficulty sustaining attention in tasks or play activities in school or at home
- Has difficulty organising tasks and activities
- Often loses things needed for tasks and activities
- Fidgets with hands/feet or squirms in seat
- Leaves seat in situations where remaining seated is expected
- Easily distracted
- Often blurts our answers before the questions have been completed
- Has difficulty awaiting turn
- Daydreams or is inattentive
Speaking
- Has trouble answering questions people ask
- Has trouble answering questions as quickly as peers
- Has trouble asking for help when needed
- Has trouble asking questions
- Has trouble using a variety of vocabulary words when speaking
- Has trouble expressing thoughts
- Has trouble describing things to people
- Has trouble getting to the point when talking
- Has trouble putting events in the right order when telling stories or talking about things that happened
- Uses poor grammar when speaking
- Has trouble using complete sentences when talking
- Talks in short, choppy sentences
- Has trouble having a conversation with someone
- Has trouble talking with a group of people
- Has trouble saying something another way when someone doesn't understand
- Gets upset when people don't understand
Word retrieval
- Knows the words they want to say but can not think of it
- Has difficulty remembering the names of known people, places or objects
- Substitutes words with a smaller word
- describes word by category, function or appearance
- Sometimes has a long delay when they cannot think of a word
- Makes false starts and revisions when relating an experience
- Uses time fillers of "um, er, oh" when trying to think of words
- Gives too much information, includes irrelevancies
Social Communication
- Decreased eye contact when interacting with others
- Frequent conflict with peers is noted by others eg. teachers
- Avoids or shows little interest in social interaction of same age peers
- Needs to be directly taught implied social rules e.g personal space
- Does not tell enough background information to the listener when telling a story.
- Has trouble staying on the subject when talking
Reading
- Has trouble sounding out words when reading
- Has trouble understanding what was read
- Has trouble explaining what was read
- Has trouble identifying the main idea
- Has trouble remembering details
- Has trouble following written directions
Writing
- Has trouble writing down thoughts
- Uses poor grammar when writing
- Has trouble writing complete sentences
- Writes short choppy sentences
- Has trouble expanding an answer
- Has trouble putting words in the right order when writing sentences
Sensory Sensitivities
- Expresses distress during grooming
- reacts emotionally or aggressively to touch
- Avoids certain tastes or food smells that are typically part of children's diets
- Picky eater particularly with food textures
- Becomes anxious or distressed when feet leave the ground
- Touches people and objects
- Doesn't seem to notice when face and hands are messy
Additional Comments & Concerns
Please detail any comments or concerns below
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Child's History

Medical History

Communication

Education History

To assist the speech pathologist obtain a complete profile of your child's strength and weaknesses, please tick below all that apply.

Additional Comments & Concerns