PARENT INPUT FORM: Speech/Language - SPED

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PARENT INPUT FORM: Speech/Language Developmental History
Confidential
Sevier County Schools/Department of Special Education/Sevierville, TN
Student Information
Name ______________________________ Date of birth _______________ Age ______
Form Completed by _____________________________ Date _______________
Parents/Legal Guardian (Check all that apply)
With whom does this child live? __Both parents __Father __Stepmother __Stepfather
__Other If so, who?_____________________________________
Parents/Legal Guardians Name(s): ______________________________________________________
Address ___________________________________________________________________________
Home phone __________________ Work phone _______________Cell phone __________________
List names and relationships of people at home: ___________________________________________
__________________________________________________________________________________
Are there any languages other than English spoken at home? ___Yes ___No If yes, what languages?
________________________ By whom? ______________________ How often? ________________
Areas of Concern (Check all that apply)
Behavioral/emotional
Slow development
Immature language usage
Difficulty understanding language
Speech difficult to understand
Vision problems
Slow motor development
Stuttering
Listening
Health/medical
Uneven development
Other ___________
Why are you requesting this evaluation? ___________________________________________________
____________________________________________________________________________________
Did anyone suggest that you refer your child?
Yes
No
If yes, name and title: _____________________________________________________________
Has a physician, psychologist, speech pathologist, or other diagnostic specialist evaluated your child?
Yes
No If yes, was a diagnosis determined?
Yes
No Please explain: _________________
_____________________________________________________________________________________
Preschool History (Check all that apply)
Preschool/daycare programs attended:
Name ______________________________Address_________________________Dates______________
Name ______________________________Address_________________________Dates______________
List any special services that your child has received (e.g. Head Start, therapy, etc.):
Type of service ______________________Age_____Dates___________School/agency_______________
Type of service ______________________Age_____Dates___________School/agency_______________
If your child has attended a preschool or daycare and problems were discussed with you about his/her
behavior, explain what was tried and if you think it worked: ______________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Page 2 Parent Input Form
Developmental History
Pregnancy and Birth
Which pregnancy was this? 1st 2nd 3rd 4th Other _____ Was it normal?
Yes
No
If no, explain any complications: ___________________________________________________________
Was your child
Full term Premature What was the length of labor? __________________________
Was the delivery: Induced? Yes No
Caesarean? Yes No
Birth weight: ____________Baby’s condition at birth (jaundice, breathing problems, etc.) _____________
______________________________________________________________________________________
Motor development (List appropriate ages.) ___________________________________________________
Sat alone ____________________ Crawled ____________________ Stood alone ___________________
Walked independently ______________________ Fed self with a spoon ___________________________
Toilet trained: Bladder _____________________ Bowel _______________________
Medical History
List any significant past or present health problems (e.g. serious injury, high temperature or fever, any twitching
or convulsions, allergies, asthma, frequent ear infections, etc.)________________________________________
__________________________________________________________________________________________
List any medications taken on a regular basis _____________________________________________________
List medical treatments (e.g. PE tubes, inhalers, ear wax removal) ____________________________________
__________________________________________________________________________________________
Speech and Language
(List appropriate ages.)
___________________Spoke first words that you could understand (other than mama or dada)
___________________Used two-word sentences __________________Spoke in complete sentences
Does the child communicate primarily using speech?
Yes No
Does the child communicate primarily using gestures?
Yes No
Is your child’s speech difficult for others to understand?
Yes No
Does your child have difficulty following directions?
Yes No
Does your child answer questions appropriately?
Yes No
Social Development:
What opportunities does your child have to play with children of his/her age? __________________________
_________________________________________________________________________________________
What play activities does your child enjoy? _____________________________________________________
Does she/he play primarily ______alone? Or _______ with other children?
Does she/he enjoy pretend play?
Yes
No
Do you have concerns about your child’s behavior? Yes No If yes, please explain: __________________
_________________________________________________________________________________________
How do you discipline your child? _____________________________________________________________
Thank you for providing the above developmental information about your child. Please return to the
Speech/language Therapist at your child’s school by _______________________(date). If you have
any questions, feel free to contact ________________________at___________________________.
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