The Center for Hearing and Speech 3636 W. Dallas Houston, TX 77019 Date: ___________________ SPEECH EVALUATION CASE HISTORY SECTION 1: PERSONAL INFORMATION Child’s Name: _______________________________________________ Gender: Ethnicity:

Child’s Social Security Number

 Male  Female  African American

DOB: ______/_______/______

 Asian-Pacific  Caucasian

______ - ______ - ________

 Hispanic

 Other

Address: Street

Apt. #

City

State

Zip Code

Home phone number: (____) _______-___________

County

Cell phone number: (____) _______-____________

E-mail Address: Father’s Name:

Mother’s Name:

Father’s Occupation:

Mother’s Occupation:

Father’s Work Number: (____) ______-

Mother’s Work Number: (____) _____-

Who referred you for today’s services? Emergency Contact: Name

Relation

Phone Number: (_____) ______-__________ Do both parents live in the home?  YES  NO

Is your child adopted/fostered?  YES  NO

Who lives in the home (age & relation to child)?:

What services are you interested in? Parent Learning Style:

 Cochlear Implant Eval.

 Written

 Pictures

 Speech Therapy

 Demonstration

 Pre-School

 Verbal Instruction

Overall, what do you hope to learn from your evaluation at The Center for Hearing and Speech? _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ 19 months to 18 years Speech Intake Packet (Non-Audiology Client)

Page | 1 Revised 2013-10-11

Name of Pediatrician/ Physician: Physician Phone: (______) _______-_____________

Physician Fax: (______) _______-_____________

Address: Street

City

State

Zip Code

SECTION 2: HEARING HISTORY Did your child pass his/her newborn hearing screening? Right Ear:  YES

 NO

 I DON’T

KNOW

Left Ear:  YES

 NO

 I DON’T

KNOW

Has your child’s hearing ever been tested?

 YES

 NO

If yes, where? _______________________________ Date of most recent test: _____/_____/______ Type/Degree of Hearing Loss: Right Ear:

Left Ear:

When was your child diagnosed? _____/_____/______

Cause of loss:

Onset of hearing loss (please check one): ___at birth ___before any language ___later (after some language) SECTION 3: EAR PROBLEMS Ear problems = ear infections or aches, drainage, hole in eardrum, fluid in ears, etc. Has your child ever had any ear problems?

YES



NO

Has your child had any ear problems in the past 6 months?  YES



NO

Did your child have ear problems before the age of 1?



NO



If yes, describe:



YES

Approximately how many ear problems has your child had in his/her life? 

0-2



3-5



6-10



11 or more

Has your child ever had tubes placed in his/her eardrums?  YES



NO

If yes, when? _____/_____/______ SECTION 4: HEARING AID/COCHLEAR IMPLANT INFORMATION Right Ear:



Hearing aid



Cochlear Implant



BAHA



None

Left Ear:



Hearing aid



Cochlear Implant



BAHA



None

When was your child fit with his/her hearing aids or BAHA? Right: _____/_____/______

Left: _____/_____/______

When was your child’s cochlear implant activated? Right: _____/_____/______

Left: _____/_____/______

CI Surgeon: ___________________________ CI Audiologist: 19 months to 18 years Speech Intake Packet (New Patient)

Page | 2 Revised 2013-10-11

Last mapping session: _____/_____/______

CI Center:

Does your child wear his/her amplification consistently at: School?



YES



NO

How many hours/day? ______

Home?



YES



NO

How many hours/day? ______

SECTION 5: PRENATAL AND BIRTH HISTORY Check all that applies to the mother during pregnancy: 

Drug Use



Medications



Alcohol Use



Smoking



Excessive Weight Loss



Trauma/Injuries



Toxoplasmosis



X-ray Treatments



Premature rupture of membranes



RH incompatibility



Hospitalization/bed rest



Previous Miscarriages



Pulmonary Hypertension



High Blood Pressure



Hemorrhaging



Diabetes



Other Illness

Please Explain:

Was this a normal delivery?  YES



NO

If no, check all that apply. 

Cesarean Section (  emergency



scheduled)



Premature Delivery (born at

weeks gestation)  Other:



Anoxia

SECTION 6: CHILD’S MEDICAL HISTORY Check all that apply. 

Allergies



Autism Spectrum Disorder



Cerebral Palsy



Cleft Palate



CMV



Craniofacial Abnormalities



Difficulties with Balance, Gait, Coordination



Extended NICU Stay



Extended Ventilation Use



High Fevers



Genetic Disorder or Syndrome (Name of Disorder/Syndrome: ______________________________)



Jaundice



Low birth weight (less than 5 pounds) Weight at birth:



Meningitis



Mumps



Ototoxic Medications



Rubella



Seizures



Vision problems



Other:



Head Trauma

Please list all allergies:

19 months to 18 years Speech Intake Packet (New Patient)

Page | 3 Revised 2013-10-11

SECTION 7: FAMILY HISTORY Family= parents, brothers, sisters, aunts, uncles, cousins and grandparents Does/Did anyone in the child’s family have: Hearing loss:

YES



NO

If yes, who?

Hearing Aids/Cochlear Implant:  YES



NO

If yes, who?

Speech problems:



YES



NO

If yes, who?

Blindness:



YES



NO

If yes, who?

Malformation of head, neck or ears:  YES  NO

If yes, who?

Mental Illness:



YES



NO

If yes, who?

Alcoholism:



YES



NO

If yes, who?

Drug Use:



YES



NO

If yes, who?

Delayed Motor Development:



YES



NO

If yes, who?

Other Medical Problems in the Family?  YES



NO If yes, who?



Please Explain: Have there been any of the following major changes in the family during the last year? 

Change of address



Accident or Illness



Divorce/Marriage



Parent Separation



Death of a family member



Birth/Adoption

Check the highest education level for each parent           

Father completed graduate school (master’s or PhD) some graduate school university degree (BA, BS, or equivalent) community college associate’s degree some college or university high school GED certificate trade school some high school elementary school no formal education

19 months to 18 years Speech Intake Packet (New Patient)

          

Mother completed graduate school (master’s or PhD) some graduate school university degree (BA, BS, or equivalent) community college associate’s degree some college or university high school GED certificate trade school some high school elementary school no formal education

Page | 4 Revised 2013-10-11

SECTION 8: DEVELOPMENT Indicate when your child first demonstrated the following: Age

Behavior

Age

Behavior

_____

cooing, pleasure sounds

_____

single words

_____

babbling (ba-ba, da-da)

_____

phrases (go bye-bye,)

_____

jargon (talking own language)

_____

short sentences

What is the primary method of communication your child uses (Check all that apply)?  looking at objects  crying  single words  pointing at objects  vocalizing/grunting  2-3 word phrases  gestures  physical manipulation Which of the following do you think your child understands (Check all that apply)?  his/her name  family names  simple directions  names of body parts  names of objects At approximately what age did your child achieve the following motor milestones? _______head support

_______reach and grasp

_______sitting alone

_______crawling

_______standing alone

_______walking alone

_______climbing stairs

_______finger foods

_______eat w/a spoon Has your child had any feeding difficulties? Check all that apply.     

sucking or nursing excessive length of time to drink bottle regurgitation of liquids or solids through nose difficulty chewing or swallowing meats choking and/or gagging

Does your child choke while eating?



YES



NO

If “yes” what foods? Is your child a picky eater?



YES



NO

Describe any feeding problems your baby experienced during the first three months of life:

Does your child drool more than other children his/her age?



YES



NO

Did your child have difficulty gaining weight as an infant?



YES



NO

19 months to 18 years Speech Intake Packet (New Patient)

Page | 5 Revised 2013-10-11

SECTION 9: HOME LANGUAGE SURVEY: How does your child communicate?  Oral Communication  Sign Language 

Sign Lang. & Voice



No Language/Gestures

Fluency in American Sign Language or Signed English:  excellent  fluent  some  limited  none What language is spoken or used in your child’s home most of the time? __________________/  English What language does your child use most of the time? __________________/  English What was the first language that your child learned? __________________/  English In what country was your child born? _______________________/  USA Has your child lived in any other country for an extended period of time? _______________________ If so, what country and for how long? _______________________ How long has your child resided in the United States? _______________________/  All his/her life SECTION 10: PLAY BEHAVIORS: Check all that describe the types of play your child engages in most often:  putting toys in mouth  pushing/pulling toys  banging toys  looking at books  throwing toys  using one object for another  acting out familiar routines  dumping toys

 shaking toys  rough and tumble play

What activities seem to hold your child’s attention for the longest period of time?

What activities seem to hold your child’s attention for the shortest period of time?

Whom does your child prefer to play with? (Circle One): Adults

Same Age Children

Younger children

Older children

Check all behaviors that describe your child  overly active  nervous  destructive  teeth grinding  excessive tantrums  thumb-sucking  stares at lights  imaginative/creative  defiant  head banging  easily controlled/passive  makes unusual noises  very shy  friendly/outgoing  hand flapping/finger  difficulty separating from flicking parent

19 months to 18 years Speech Intake Packet (New Patient)

Alone

 perfectionist  overly quiet  interrupted/unusual sleeping habits  interrupted/unusual eating habits

Page | 6 Revised 2013-10-11

SECTION 11: INTERVENTION SERVICES Does your child receive any of the following (please check all that apply) 

Occupational Therapy:

How Long: _________

Number of Times per Week: _________

How Long: _________

Number of Times per Week: _________

How Long: _________

Number of Times per Week: _________

Organization/Clinic: 

Physical Therapy: Organization/Clinic:



Speech Therapy: Organization/Clinic:



Auditory Impaired (AI) Services: How Long: _________ Number of Times per Week: ______ Organization/Clinic:

Is your child seen for the following services?  Vision Impaired  Feeding/Swallowing/Oral Motor? How Long/Number of Times per Week of Each: Does your child receive Early Childhood Intervention (ECI) services at home?  YES  NO SECTION 12: EDUCATIONAL PLACEMENT Does your child attend day care or school?  YES



NO

( daycare



school)

Name of School: ______________________________________ Grade: ______________ School District: _______________________________________ What type of classroom is your child in?  Regular

Education

 Special

 Hearing

Impaired ( Spoken Language

 Total

Education

Communication

 PPCD  American

Sign Language)

Please list the modifications your child receives in school (if any): _______________________________________________________________________________________ _______________________________________________________________________________________

19 months to 18 years Speech Intake Packet (New Patient)

Page | 7 Revised 2013-10-11

The Center for Hearing and Speech 3636 W. Dallas Houston, TX 77019

PARENT COMMITMENT AGREEMENT In order for children to be successful oral communicators, it is of the utmost importance that they are hearing to their maximum potential every day. The Center for Hearing and Speech is committed to your child’s success, we will do everything in our power to ensure a positive experience. However, we need your help! Below is a list of parental expectations that will maximize your child’s ability to benefit from this program. Please review these guidelines carefully and indicate your commitment to this program by initialing each line and signing below.

_____ I will arrive at The Center with my child wearing all recommended amplification (hearing aids, FM, cochlear implant) in good working order. If there is a broken or non-functioning part, I will immediately inform the audiology staff.

_____ I will assure that my child wears his/her amplification all waking hours.

_____ I will keep the speech therapist up to date on any audiologic testing performed at other facilities.

_____ I will obtain further evaluations/intervention for my child, if recommended.

_____ I will pay for services/supplies rendered/dispensed or within 10 days of receipt of notice. Failure to comply with these guidelines can put your child’s auditory verbal learning potential at risk and may result in the removal of your child from his/her reserved time slot with recommendations to attend a different program that may better fit your needs.

____________________________________ Parent’s Signature

19 months to 18 years Speech Intake Packet (New Patient)

______________________________ Date

Page | 8 Revised 2013-10-11

The Center for Hearing and Speech 3636 W. Dallas Houston, TX 77019

SPEECH REFERRAL REQUIREMENTS Because there are many insurance and Medicaid plans with differing requirements for referrals to specialists, The Center for Hearing and Speech requires that you obtain a written referral from your primary care physician and submit with this packet.

Directions Please call your child’s PCP (Primary Care Physician), ask for the Referral Specialist and request a written referral to The Center for Hearing and Speech. Your Child’s Name:_______________________________________________________ Your Child’s PCP:_______________________________ Phone:________________ Referral Representative is:________________________

Fax: ___________________

Every six months or so the Billing Coordinator will need to request an updated written referral depending on your Child’s medical coverage. Please fill in the information above. This form will be collected for your child’s financial folder and used to obtain the referrals. Please report any PCP changes to the Billing Coordinator.

If you have questions, please contact: Billing Coordinator Direct: 713-337-6718 Fax: 713-523-8399 [email protected]

Please note: Medicaid clients require authorization every 6 months for Speech Therapy. You may be contacted by our financial office to help obtain a written referral if your child’s PCP is not responding to our attempts.

19 months to 18 years Speech Intake Packet (New Patient)

Page | 9 Revised 2013-10-11

The Center for Hearing and Speech 3636 W. Dallas Houston, TX 77019

RELEASE FOR PROMOTIONAL/FUNDRAISING PURPOSES PHOTOGRAPHS I hereby give permission for The Center for Hearing and Speech to photograph my child and to have such pictures appear on the website and related websites (Facebook, Flickr) and in newspapers, magazines, and/or other printed materials for promotional/fundraising purposes (grants, CHS newsletters, etc) as specified below: _____Yes, you may photograph my child and use his/her name (first name only) _____Yes, you may photograph my child, but you may not use his/her name _____No, you may not photograph my child or use his/her name

VIDEOTAPING I hereby give permission for The Center for Hearing and Speech to videotape my child and to have such footage appear on the website and related websites (Facebook), at special events and for special fundraising videos: _____ Yes, you may videotape my child and use his/her name (first name only) _____ Yes, you may videotape my child, but you may not use his/her name _____No, you may not videotape my child or use his/her name

___________________________________________ CHILD’S NAME

___________________________________________ PARENT’S SIGNATURE

19 months to 18 years Speech Intake Packet (New Patient)

________________________ DATE

Page | 10 Revised 2013-10-11

The Center for Hearing and Speech 3636 W. Dallas Houston, TX 77019

UNIVERSITY TRAINING PROGRAM PERMISSION TO RECEIVE INTERN SUPERVISED SERVICES Child’s Name: ______________________________________

Date: _________

The Speech Clinic at The Center for Hearing and Speech provides training to undergraduate and graduate level university students. As part of this program, clients may be observed by undergraduate clinicians or may receive direct care from graduate students under the direct supervision of a licensed speech-language pathologist. Please circle yes / no to indicate consent Yes / No I give permission for my child to receive intervention from a graduate student under the supervision of an SLP for the fall / spring / summer 20____ semester. Yes / No I give permission for my child’s session to be observed by undergraduate clinicians via live-camera feed. I understand I will be informed when sessions are being observed. If “yes” is circled, please initial the following: ____

I understand that participation in the University Training Program is voluntary and consent can be withdrawn at any time with only a verbal request.

_____ I understand that each student who works with my child will have observed 10 hours of speech therapy by a licensed and skilled therapist and completed at least three hours of lecture including video observation of techniques. ____

I understand that if I have any questions about the University Training Program, that I may contact the Director of the Speech Clinic at extension 131.

___________________________________ Parent/Caregiver Signature

19 months to 18 years Speech Intake Packet (New Patient)

___________ Date

Page | 11 Revised 2013-10-11

The Center for Hearing and Speech 3636 W. Dallas Houston, TX 77019 EARLY CHILDHOOD INTERVENTION (ECI) RELEASE OF INFORMATION FORM (Please Complete if Your Child is Younger than 3 Years) This form has been designed to facilitate communication among your child’s ECI providers and The Center for Hearing and Speech. Please contact the Coordinator of Intervention Services (713-337-9079) with any questions regarding the completion of the form. Child/Client Name:

DOB:

Does your child receive Early Childhood Intervention (ECI) services at home?  YES

 NO

Date services started: _____/_____/______ Does your child receive any of the following (please check all that apply)  Developmental Therapy:

My Child is seen (check one):  Weekly

 Monthly

Name/Phone # of Therapist:  Occupational Therapy:

My Child is seen (check one):  Weekly

 Monthly

Name/Phone # of Therapist:  Physical Therapy:

My Child is seen (check one):  Weekly

 Monthly

Name/Phone # of Therapist:  Speech Therapy:

My Child is seen (check one):  Weekly

 Monthly

Name/Phone # of Therapist:  Auditory Impaired (AI) Services:

My Child is seen (check one):  Weekly

 Monthly

Name/Phone # of Therapist: Is your child seen for the following services?  Vision Impaired  Feeding/Swallowing/Oral Motor? Authorization: I authorize The Center for Hearing and Speech to release / obtain / both (circle one) information to/from the professionals listed above. All information shared is pertinent to the continuity of medical care and treatment for the patient listed above. I, the undersigned, understand that I may revoke this consent at any time except to the extent that action has been taken in reliance on it and in any event this consent shall expire 12 months from the signed date. I, the undersigned, understand that a copy of this signed consent is as acceptable as the original. I, the undersigned, understand that this authorization is voluntary and I may revoke consent at any time. TO THE PARTY RECEIVING THIS INFORMATION: This information had been disclosed to you from records whose confidentiality is protected by Federal law regulations (42 CFR part 2) which prohibits you to make any further disclosure without the specific written consent of the person to whom it pertains or is otherwise permitted by such regulations. ________________________________ Signature of Parent or Legal Guardian 19 months to 18 years Speech Intake Packet (New Patient)

_______________________________ Date

Page | 12 Revised 2013-10-11

The Center for Hearing and Speech 3636 W. Dallas Houston, TX 77019 INFORMATION EXCHANGE & RELEASE OF INFORMATION FORM This form has been designed to facilitate communication among your child’s audiology team, school personnel, and other private therapist/s. Please contact the Coordinator of Intervention Services (713-337-9079) with any questions regarding the completion of this form. Child/Client Name:

DOB:

Authorization: I authorize The Center for Hearing and Speech to release / obtain / both (circle one) information to/from the following organizations listed below. All information shared is pertinent to the continuity of medical care and treatment for the patient listed above. Pediatrician or Primary Care Doctor: Address:

City/State:

Zip:

Telephone Number: Audiologist: Clinic Name/Organization: Telephone Number:

Fax Number:

Email Address: School: Address:

City/State:

Zip:

Telephone Number: Speech Therapist: Clinic Name/Organization: Telephone Number:

Fax Number:

Email Address: Other: Address:

City/State:

Zip:

Telephone Number: I, the undersigned, understand that I may revoke this consent at any time except to the extent that action has been taken in reliance on it and in any event this consent shall expire 12 months from the signed date. I, the undersigned, understand that a copy of this signed consent is as acceptable as the original. I, the undersigned, understand that this authorization is voluntary and I may revoke consent at any time. TO THE PARTY RECEIVING THIS INFORMATION: This information had been disclosed to you from records whose confidentiality is protected by Federal law regulations (42 CFR part 2) which prohibits you to make any further disclosure without the specific written consent of the person to whom it pertains or is otherwise permitted by such regulations.

Signature of Parent or Legal Guardian

19 months to 18 years Speech Intake Packet (New Patient)

_______________________________ Date

Page | 13 Revised 2013-10-11