Chatter Form

Identifying and Family Information

Child's Name *

Mother’s Name

Father's Name

Address

City

Birthdate

Year

Month

Day

Daytime Phone

Cell Phone

E-mail

FSCD worker

FSCD’s Phone

Child live with Other...

Other children in the family

School Information

Name of school and grade in school

Medical History

Has your child had any of the following

Is your child currently (or recently) under a physician’s care?

Yes

No

Please list any medications your child takes regularly

Speech & Language

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

Yes

No

If yes, which one?

Does the child speak the language?

Yes

No

Does the child understand the language?

Yes

No

Who speaks the language?

Which language does the child prefer to speak at home?

Do you feel your child has a speech problem?

Yes

No

If yes, please describe:

Do you feel your child has a hearing problem?

Yes

No

If yes, please describe:

Has he/she ever had a speech evaluation/screening?

Yes

No

If yes, where and when?

What were you told?

Has he/she ever had a hearing evaluation/screening?

Yes

No

If yes, where and when?

What were you told?

Has your child ever had speech therapy?

Yes

No

If yes, where and when?

What was he/she working on?

Has your child received any other evaluation or therapy (physical therapy, counseling, occupational therapy, vision, etc.)?

Yes

No

If yes, please describe:

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

Current Abilities

Does your child…

repeat sounds, words, or phrases over and over?

understand what you are saying?

retrieve/point to common objects upon request (ball, cup, shoe)?

follow simple directions ("shut the door" or "get your shoes")?

respond correctly to yes/no questions?

respond correctly to who/what/where/when/why questions?

Your child currently communicates using…

Your child currently communicates using… Other...

Does your child display any of the following behavioral characteristics?

Does your child have difficulty in any of the following areas?

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Identifying and Family Information

School Information

Medical History

Speech & Language

Current Abilities