Classic form

Speech pathology intake form as a child case history

A paediatric speech pathologist starts from a case history that reaches back to birth, because prematurity, early feeding and the age of first words each change what a delay is likely to be. This twenty one field intake form collects that history, the hearing testing, the languages spoken at home and the funding, before the first forty five minute session begins.

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Child case history

Clear Voice Speech, Newcastle. One form per child. Your speech pathologist reads it before the first session, which is why the first session can be spent with your child rather than on paperwork.

The child

Child's name *

First

Middle

Last

Child's date of birth *

Parent or guardian name, and relationship to the child *

Mobile *

Email *

Why you are here

What are you worried about, in your own words? *

Who suggested this appointment? *

Nobody, this was our own decision

Child and family health nurse

GP or paediatrician

Preschool or school teacher

Another therapist already seeing the child

NDIS early childhood partner

Birth and early history

The four questions below are health information about your child and are read only by the treating speech pathologist. Approximate answers are fine. Prematurity, a stay in special care and early feeding difficulty each raise the chance of a speech or language delay, which is why they are asked even when they seem long ago.

Weeks of pregnancy at birth *

Birth weight *

Time in special care or a neonatal unit, if any

Feeding in the first year

Milestones

Fill in the ages you remember for these six: first words, putting two words together, short sentences, sitting without support, walking, and being understood by somebody outside the family. Write the milestone in the first column and the age in the second. An age in months is easier to read than a date.

Milestones and the age they happened

#	Milestone	Age it happened	Anything you noticed at the time
1
2
3
4
5
6

Hearing

Has your child had a hearing test? *

Yes, in the last twelve months, result was normal

Yes, in the last twelve months, something was found

Yes, but more than a year ago

Only the newborn screen at the hospital

The newborn screen was not passed

Never tested

Not sure

Date of the most recent hearing test, if you know it

Language at home

Which languages are spoken at home? *

English

Mandarin

Arabic

Vietnamese

Cantonese

Punjabi

Greek

Italian

Auslan

An Aboriginal or Torres Strait Islander language

Another language, named at the first visit

Which language is your child strongest in? *

English

Another language spoken at home

About equal in two languages

Too early to tell

School and supports

Preschool or school, and the class or room *

Teacher or educator, and anything they have raised

Is there an NDIS plan? *

Yes, plan managed

Yes, self managed

Yes, agency managed

Access request submitted, waiting on a decision

No, paying privately

No, using a Medicare chronic disease referral

Who else is already involved? *

Paediatrician

Occupational therapist

Physiotherapist

Psychologist

Audiologist

Early childhood educator with a support plan

Another speech pathologist, now or previously

Nobody else yet

Consent

By signing you confirm that you have parental responsibility for this child and that the information above is accurate. You consent to assessment and therapy, and to your speech pathologist contacting the school or other professionals named above where that helps the work. Reports are written for you first; nothing goes to a school or a funding body without your say so.

Parent or guardian signature *

Every field, and what it collects

The complete field list, in the order respondents meet it.

Child's nameNameRequired
Child's date of birthDateRequired
Parent or guardian name, and relationship to the childShort textRequired
MobileShort textRequired
EmailShort textRequired
What are you worried about, in your own words?Long textRequired
Who suggested this appointment?Single choiceRequired: Options: Nobody, this was our own decision · Child and family health nurse · GP or paediatrician · Preschool or school teacher · Another therapist already seeing the child · NDIS early childhood partner
Weeks of pregnancy at birthShort textRequired
Birth weightShort textRequired
Time in special care or a neonatal unit, if anyShort text
Feeding in the first yearShort text
Milestones and the age they happenedTable: Columns: Milestone · Age it happened · Anything you noticed at the time
Has your child had a hearing test?Single choiceRequired: Options: Yes, in the last twelve months, result was normal · Yes, in the last twelve months, something was found · Yes, but more than a year ago · Only the newborn screen at the hospital · The newborn screen was not passed · Never tested · Not sure
Date of the most recent hearing test, if you know itDate
Which languages are spoken at home?Multiple choiceRequired: Options: English · Mandarin · Arabic · Vietnamese · Cantonese · Punjabi · Greek · Italian · Auslan · An Aboriginal or Torres Strait Islander language · Another language, named at the first visit
Which language is your child strongest in?Single choiceRequired: Options: English · Another language spoken at home · About equal in two languages · Too early to tell
Preschool or school, and the class or roomShort textRequired
Teacher or educator, and anything they have raisedShort text
Is there an NDIS plan?Single choiceRequired: Options: Yes, plan managed · Yes, self managed · Yes, agency managed · Access request submitted, waiting on a decision · No, paying privately · No, using a Medicare chronic disease referral
Who else is already involved?Multiple choiceRequired: Options: Paediatrician · Occupational therapist · Physiotherapist · Psychologist · Audiologist · Early childhood educator with a support plan · Another speech pathologist, now or previously · Nobody else yet
Parent or guardian signatureSignatureRequired

What each block of this form collects

The child and the guardian are separated at the top, with the relationship asked in words rather than a dropdown, because the person filling it in is as often a grandparent or a foster carer as a parent. The concern question comes before any structured field so the parent writes what they actually notice, which is usually more specific than any checklist. Birth history is four short fields instead of a paragraph, since gestation, weight, special care and early feeding are each a separate risk marker and a parent answers them faster as four boxes. Milestones are a table rather than six questions, and the paragraph above names the six so nothing is guessed. Hearing, home language, school and funding follow, each of which decides something about how therapy is delivered rather than what is wrong.

The Australian pieces on this form

Funding is asked as an NDIS plan question with three management types, because plan managed, self managed and agency managed change who the practice invoices and how quickly it is paid. An access request submitted and waiting on a decision is its own option, since a family in that position often starts privately and switches later. The last option names a Medicare chronic disease referral, which is the other common route for a child seeing an allied health professional here. The hearing question separates the newborn screen every Australian baby is offered in hospital from a later diagnostic test, and it offers an option for a screen that was not passed, which is the single answer most likely to change the first session. Speech pathologists here work to the professional association standards, and NDIS registered providers to the commission practice standards.

How to adapt this form

A practice that works with adults after stroke replaces the entire birth and milestone section with a date of the event, the hospital, the side affected and a swallowing screen, and swaps the guardian signature for the client's own with a space for a substitute decision maker. A stuttering clinic adds an onset date, a family history question and a recording of ninety seconds of connected speech. A classic file upload takes only images and PDF, so that version is built as a conversational form with a recording field, or asks the parent for a link to the audio.

What makes this form work

Six milestones, named in the paragraph above the table

First words, two words together, short sentences, sitting, walking and being understood outside the family. The table has three columns and six rows, and the paragraph tells the parent exactly which six to write, so nobody has to invent a list.

The hearing question can stop therapy starting

Seven options, one of which is that the newborn screen was not passed. Untreated hearing loss explains a speech delay better than anything a speech pathologist can test for, and the form asks about it before the first session rather than after four of them.

Home language and strongest language are two questions

A child can hear four languages and be strongest in one, or be genuinely balanced across two, or be too young to tell. Assessment is done in the strongest language, so asking only which languages are spoken would leave the practice measuring the wrong one.

Questions people ask

Why does a speech pathology form ask about birth weight and prematurity?

Because both change the likelihood and the shape of a delay. A child born at thirty four weeks is developmentally younger than the birth date suggests for the first couple of years, and time in special care often comes with early feeding difficulty. Four short fields collect it in under a minute and save a set of questions in the room.

What if a parent cannot remember the milestone ages?

Approximate ages are useful and the welcome screen says so. What matters clinically is the order and the rough spacing, not whether first words were at thirteen months or fourteen. A blank row is better than a guess that is years out, and the third column lets a parent write what they noticed instead of an age.

Why does the hearing question have seven options?

Because the answers behave differently. A normal test last year, a test that found something, an old test, the newborn screen only, a screen that was not passed, never tested and not sure lead to five different next steps. A yes or no would collapse the one answer that stops therapy starting, which is a screen that was not passed.

Does speaking two languages at home cause a speech delay?

No, and the form asks about home languages for a different reason. A bilingual child is assessed against their strongest language, not against English, so the practice needs to know which that is before it measures anything. The strongest language question includes too early to tell, because for many toddlers that is the accurate answer.

What do the three NDIS management types change?

Who pays the invoice. Plan managed means a third party pays the practice on the participant's behalf, self managed means the family pays and claims back, and agency managed means the practice claims through the portal. None of them changes the therapy, which is why the question sits with school and supports rather than with the clinical history.

Who is allowed to sign this form?

Somebody with parental responsibility for the child, which the consent paragraph states in those words above the signature field. That covers a parent, a legal guardian or a carer with a court order. Where two guardians must both agree, the practice sends a second copy of the form rather than relying on one signature to speak for both.

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Other form examples

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Physiotherapy intake form built around one injury

A physiotherapist has about forty minutes and needs a third of it to examine, so the history has to arrive before the patient does. This eighteen field intake form maps the region and side, the onset, the pain score and what aggravates it, then records which funding pathway is paying.

Occupational therapy intake form built on a daily living grid

An occupational therapist is asked to change how a day works, so the intake has to describe the day rather than the diagnosis. This eighteen field intake form takes an eight task support grid, the equipment already in the house, and the funding with its plan dates, before the first home visit is booked.

Want the steps in the builder? Read Every form field and when to use it, then Design your welcome and thank you screens. For everything this generator can do, see the form maker.

Sources

Written and checked by the OneCraft team. Last checked 29 September 2026.