Adult Case History - Speech Journey

Name

First

Last

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Person Filling Out Form

Relationship to Client

Birthdate

Mailing Address

Address Line 1

Address Line 2

City

State

Zip Code

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Phone

Email

Highest Grade Completed/Degree(s) Earned

Marital Status

Name and Ages of Individuals Living in Your Home

Name and Ages of Your Children (If Any)

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Emergency Contact Name

Emergency Contact Phone Number

Referred By

Speech and Language History

Please Explain Your Current Speech And Language Issues And The Reason For This Evaluation

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Is English Your First Language?

Yes
No

Are You Bilingual?

Yes
No

What Was The Approximate Age That You Began Having Difficulty With Fluency?

Are You Currently Receiving Or Have You Received Speech Therapy In The Past?

Yes
No

Please Note Your Current Disfluency Patterns (Check All That Apply)

Repetitions Of The First Letter (B-b-boy)
Repetitions Of The Whole Word (Boy-boy-boy)
Repetitions Of Part Of The Word (Ca-ca-cat)
Prolongations Of Sounds (Mmmmmom)
Silent Blocks Before Speaking (-----boy)
Fillers (Um, Well, Uh)
Changing Words Or Starting Over
Other

Are There Any Periods (Days, Weeks, Months) When Stuttering Either Increases Or Decreases?

Yes
No

Does Your Stuttering Fluctuate Or Remain Consistent?

Would You Describe Your Speech Difficulty As Mild, Moderate Or Severe?

What Do You Hope To Gain From This Evaluation?

Do You Have Any Other Speech And Language Concerns?

Medical, Developmental, and Family History

To The Best Of Your Knowledge, Was Your Speech And Language Development On Target?

Yes
No

How Is Your Present Health?

Excellent
Good
Fair
Poor

Have You Ever Been Hospitalized?

Yes
No

Do You Have Any Chronic Or Current Medical Problems?

Yes
No

Are You Presently Taking Supplements and/or Medications

Yes
No

Family History of Stuttering

It is helpful to ask relatives about a possible history of stuttering.

Mother

Ever Stuttered?
Still Stutter?
Had Therapy?

Please Select All That Apply

Father

Ever Stuttered?
Still Stutter?
Had Therapy?

Please Select All That Apply

Other Family Members

Ever Stuttered?
Still Stutter?
Had Therapy?

Please Select All That Apply

Treatment and Observation Release Form

Permission

I give permission for Speech Journey to observe and videotape me under the supervision of your clinician, by the treatment staff, and/or interns. The purpose of this observation is to assess you and to advance the education and treatment of those who stutter.
I do not give permission to Speech Journey to observe and/or videotape me.

I Hereby Grant Permission To Speech Journey To Release Information On My Behalf To The Following Agencies/Persons

I Hereby Grant Permission To Speech Journey To Request Information On My Behalf From The Following Agencies/Persons

Upload Copies of Any Previous Evaluations

Click or drag files to this area to upload. You can upload up to 5 files.

Client Name

First

Last

Client Signature

Sessions

Sessions are usually one hour in length, which includes any time necessary for parent consultation, scheduling and billing issues.

Commitment/Scheduling

Your treatment and care are of the utmost importance to me and I value nurturing a mutually respectful relationship with you and your family. A strong commitment to the process is essential for steady progress.

Once a session is scheduled, 24-hour notice is required for any cancellation or postponements. Clients will be charged in full for any session cancelled less than 24-hours in advance. I will do my best to accommodate a makeup session. However, if we cannot find a mutually desirable time to reconvene within a one-week period, it will be considered a cancellation and the full session fee will be charged.

Occasionally, I may ask if you can move a session time. Please know if I am doing so, it is probably because I am trying to accommodate another client and that your scheduled session comes first.

Billing

Payments may be made via cash or check (made out to “Speech Journey”). There will be a $35 fee charged for any returned checks.

Insurance reimbursement may be possible. You will be provided with receipts of payment to submit to your insurance company. It is your responsibility to inquire about your plan’s benefits. I will provide whatever assistance I can in helping you receive the benefits to which you are entitled, however, you (not your insurance company) are responsible for full payment of my fees.

Your signature below indicates that you have read this agreement and agree to its terms.

Client Name

First

Last

Signature of Client or Parent/Guardian

ADULT CASE HISTORY FORM

Speech and Language History

Medical, Developmental, and Family History

Family History of Stuttering

Treatment and Observation Release Form

Sessions

Commitment/Scheduling

Billing

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