Your Child’s Development History – details required ahead of your child’s assessment for speech and language difficulties

This information is essential for your child’s initial assessment.

Where you have answered yes to the questions, please explain and describe what you have observed and/or give examples in the space provided. Please provide as much detail as possible to help the speech and language therapist understand your child's difficulties. You may find your child’s 'My child’s personal health record' (red book) helpful when answering some of the questions.

Please be aware this form may take up to 20 minutes to complete. Incomplete forms will not be submitted.

To be completed by child's parent/carer

Name of child *

Date of birth *

Name of person completing this form *

Relationship to child *

Name of the child's next of kin *

Contact number for child's next of kin *

What is the main language spoken at home? *

Are there any other languages spoken at home? *

Yes No

Please provide details

Will you need an interpreter at any appointments we may offer? *

Yes No

Please provide details

Current concerns

Does your child have any difficulties with listening and concentrating? *

If yes, please provide detail

Does your child have any difficulties interacting with other people? *

If yes, please provide detail

Does your child have any difficulties understanding what people say? *

If yes, please provide detail

Does your child have any difficulties saying sounds and words? *

If yes, please provide details including a list of sounds that the child is unable or finds difficult to say

Does your child have any difficulties with stammering or stuttering when they talk? (For example, do they repeat the first word or whole words?) *

If yes, please provide detail

Does your child have any voice difficulties? (For example, their voice is husky or do they whisper when they talk?) *

If yes, please provide detail

Does your child have any difficulties putting sounds, words and sentences together to share information, ideas and wishes? *

If yes, please provide detail. For example, how many words does your child put together in a sentence?

Does your child have any difficulties with eating or feeding, drinking or swallowing? *

If yes, please provide detail

Please add any further details or information in here

Birth history

Were there any complications during the pregnancy? *

Were there any complications during the birth? *

Were there any difficulties with feeding in the first year? *

Did your child have a dummy/ still use a dummy/ or suck their fingers? *

Where you have answered yes to the questions above, please explain and describe what you have observed and/or give examples here. Please provide as much detail as possible to help the speech and language therapist understand your child's difficulties.

Milestones and early development

Did you experience any difficulties moving from liquid feeding to solid foods with your child? *

If yes, please provide detail

Do you have any concerns about your child's development, for example do you find they are sometimes clumsy or they struggle to pick up objects? *

If yes, please provide detail

When your child was a baby did they babble a lot? *

If yes, please provide detail

When your child was a baby were they particularly quiet? *

If yes, please provide detail

When did you your child achieve the following? Please detail the year and month

Sitting

Crawling

Walking

Toilet training

How old was your child when they said their first words? The word doesn't have to be said correctly, just that you knew what your child was saying. Please detail the year and month *

Medical history

Has your child had speech and language therapy in the past? *

If yes, please provide detail

Has your child had any infections / prescribed medication / hospital visits? *

If yes, please provide detail

Do you have any concerns about your child's hearing at the moment? *

If yes, please provide detail

Since birth, has your child's hearing been checked? *

If yes, please provide detail

Has your child had any ear infections in the past? *

If yes, please provide detail

Do you have any concerns regarding your child's vision? *

If yes, please provide detail

Family history

Are you aware of any history of speech and language difficulty in the family? *

If yes, please provide detail

Does your child have any brothers and sisters? *

If yes, please provide detail

Did they have any speech and language difficulties? *

If yes, please provide detail

Are there any other services or professionals, such as social care or health visitors, working with your child? *

Please provide details of the organisation

Socialisation / play

What does your child enjoy doing at home e.g. what play activities do they like, do they like to read, colour, draw - please describe.

Education

Is your child at pre-school or school?

Name of pre-school/school and teacher

Times and sessions attended (pre-school children only)

Has the pre-school or school highlighted any concerns to you regarding your child's speech and language? please explain.

Outcomes

What outcomes are you hoping for from the referral to our Speech and Language Therapy Service?

Forms