General Case History - Speech Journey

Please submit this form prior to our first meeting. At the bottom of the form you’ll also have an opportunity to upload copies of any previous evaluations.

Name *

First

Last

Person Filling Out Form *

Relationship to Client *

Birthdate *

Mailing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Cell Phone *

Email *

Highest Grade Completed/Degree(s) Earned *

Are You Currently Employed? *

Handedness *

Right-Handed
Left-Handed
Ambidextrous

Marital Status *

Name and Ages of Individuals Living in Your Home *

Name and Ages of Your Children (If Any) *

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 *

Is English Your First Language? *

Are You Bilingual? *

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

Please Note Your Current Physical Behaviors Observed During Speech (Check All That Apply) *

Eye Blinking
Head Nodding
Hand Or Foot Movement
Difficulty Breathing
Squeezing Eyes Shut
Looking Away

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

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? *

How Is Your Present Health? *

Excellent
Good
Fair
Poor

Have You Ever Been Hospitalized? *

Do You Have Any Chronic Or Current Medical Problems? *

Are You Presently Taking Supplements and/or Medications? *

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

Outcome of Therapy?

Father *

Ever Stuttered?
Still Stutter?
Had Therapy?

Please Select All That Apply

Outcome of Therapy?

Other Family Members *

Ever Stuttered?
Still Stutter?
Had Therapy?

Please Select All That Apply

Outcome of Therapy?

What is Your Child’s Understanding of Language? Following Directions? *

What is Your Child’s Use of Language Like? What Do They Say? Vocabulary They Use? And Word Order? *

Please Describe Specific Sound Changes That You Hear *

Is Your Child A Good Eater Or A Selective Eater? *

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.

Permission 2 *

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 *

Clear 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 *

Clear Signature

GENERAL 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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