Test Case History Details

business-cat-paperworkYou should have been sent this link by your therapist, Marijke.

Please complete it as best as you can.

Once submitted, this form will be emailed to Marijke, as well as a copy to your own email ID.


 

The Child Case History Form helps the clinician have a good understanding of your clinical journey so far. The therapist ideally will receive this form a few days in advance of your first assessment session and may discuss it with you on the day in order to seek more information, or clarify any points you raise in it. Although this can be completed on a Smartphone, we would recommend using a tablet, PC or laptop for best results.
Contact Details
This section is to ensure we have correct any and all contact and personal details required so we can best assist you. If there is a question which you would rather not answer on this form, please write in 'Will discuss with therapist'.
This is your child's name, or the name of the person requiring assessment.
Date in DD/MM/YYYY
Key People
This section contains the details of the key people in this person's life. Please complete for any or all who you feel apply.
Home Life
Please state the sibling's: Name : Age : Any difficulties/Concerns : Preferred Hand.
Please give us some information on anything your child likes, or is interested in. (e.g. Favourite TV shows, Characters, Colours, Foods, Toys etc.)
School / Creche Details
What is your child currently attending, e.g. School/ Preschool etc.
Please put in the best phone number to use should we need to contact the child's school.
Does your child have an SNA? If so, please can you add their name.
Background to Referral
Please select if you are referring to a Speech and Language Therapist, Occupational Therapist or Both.
E.g. HSE, Lucena Clinic, Psychologist, Ear-Nose and Throat Consultant, Hospital? If so, please state individual’s name and profession: (If you have received reports from any of the above, or if you have an Assessment of Need Report, please include it.) This form allows space to upload documents at the end of this question.
I give consent to the CATTS therapist to contact the other professionals/agencies who are involved with my child’s service provision
Max file size is 128 MB.
Max file size is 128 MB.
Max file size is 128 MB.
Max file size is 128 MB.
Max file size is 128 MB.
Medical History
All these sections require an answer. Please simply type in 'No', or 'NA' if they do not apply. This helps indicate that you have read the question and have answered.
Have the following been tested?
When was vision last tested. By whom? Any results or comments to note.
When was hearing last tested. By whom? Any results or comments to note.
Birth and Developmental History
Anything which you feel we should know about. Were there any complications during pregnancy or at birth? If so please specify.
When did your child:
Please provide ages and examples below:
Speech and Language
Please feel free to skip this section if you are referring for Occupational Therapy only.
Occupational Therapy
Please feel free to skip this section if you are referring for Speech Therapy only. Please give a general idea of your child’s abilities (Select and/or comment):
Activities of Daily Living
Dressing
Learning Abilities. Does your child:
Please provide any additional information that might be helpful in the assessment or therapy intervention of the child’s problem.
Thank you for completing this form. If you are ready, you may now hit the Submit button.