Social Skills Form

Patient History – Child

Your Name (required)

Date of Birth (required)

Age (required)

Sex (required)
MaleFemale

Address (required)

City (required)

State (required)

Zip (required)

Your Phone (required)

Your Email(required)

Person Completing This Form (required)

Relationship to Client (required)

Mother's Name (required)

Mother's Age (required)

Mother's Address (required)

Mother's City (required)

Mother's State (required)

Mother's Zip (required)

Father's Name (required)

Father's Age (required)

Father's Address (required)

Father's City (required)

Father's State (required)

Father's Zip (required)


MEDICAL HISTORY

List all children in the family from oldest to youngest (Name,age,sex,grade in school, general health)

Child's pediatrician or family doctor

Doctor Address

Has the child had any previous testing or therapy for speech, language or hearing problems
YesNo

Please use the space below to write additional family information that you feel is relevant:


EDUCATION HISTORY

Date and type of last medical examination

Has the child had any ear trouble (such as earaches, infection, running ears, evidence of hearing loss)?
YesNo

If yes, please describe:

Has hearing been tested?
YesNo

If yes, please when:

Results:

Has the child ever had ear (PE) tubes inserted?
YesNo

If yes, please when:

If yes, does the child still have ear (PE) tubes?
YesNo

Has the child ever worn eyeglasses or had any difficulty with eyes?
YesNo

If yes, please describe:

Has the child seen a specialist for any reason?
YesNo

If yes, please when:

Please use the space below to provide any other important medical information:

DAILY BEHAVIOR

Current School:

Address

City

State

Zip

Grade

Does the child like school?
YesNo

Does the child like the teacher?
YesNo

Describe performance in school (please note strong and weak areas)

Does the child attend any special classes (such as speech therapy, language development, reading, resource room, special education classroom)?

If yes, please describe:

Please use the space below to write additional family information that you feel is relevant:

COMMUNICATION HISTORY

Where does the child usually socialize?

Does the child prefer to play alone?
YesNo

Does the child prefer to play with older or younger children?

Does the child have a close friend?
YesNo

What are your most frequent discipline problems with this child?

Who does the disciplining?

How do you discipline?

What does the child do well?

What does the child have trouble doing?

Does the child have difficulty concentrating?

Please use the space below to write additional family information that you feel is relevant:

AGREEMENT TERMS

Is the child’s speech understandable to;
to you.to friends.to strangers.to other family members?

List sounds or words that the child has trouble saying

How does the child compare with siblings in communication development?

Does the child use words in meaningful ways for his/her age?
YesNo

Does the child seem to understand directions?
YesNo

Do you have any further questions?

Please use the space below to write additional family information that you feel is relevant:

step 7

By signing below, you agree to the following:

1. I agree to have my child screened by a speech language pathologist to ensure proper
group placement.

2. I understand that my child may not be placed into a group if the speech language
pathologists feels my child is not ready for a social skills group or if my child does not
fit into an appropriate group.

3. I agree to allow graduate students from local universities or other qualified professionals
to observe and participate in treatment sessions, under the supervision and direction of a
certified speech language pathologist.

4. I understand that my $100 deposit is non-refundable unless my child is not placed into a
group per the speech language pathologist. I understand that I am not refunded the money
in the event that I, personally, choose not to have my child participate. By placing a
deposit, I know that I have signed up and secured my group spot.

5. I agree to pay the remaining $250 (group is $350 total) for 8 treatment sessions. I
understand the balance is due before the first session date. Invoices are sent via email. I
can choose to either pay online or send a check via mail to Metro East Therapy at 60 S.
State Route 157 suite 20, Edwardsville, IL. 62025. Checks are made payable to Metro
East Therapy, Inc.

Patient or Parent/Guardian Signature

Relationship to Child

Date

I agree