Need to complete a form?  Just select the Form below and fill it in:

Please note that the Speech/CaseHistory Form can be completed and submitted online.

For Authorizations, please either enter the information and then print, or print the form and then enter the information by hand.

In both cases, the Authorizations must be signed and mailed to our office to become effective.  Please mail to us at:

Nichols Speech & Language Services

41689 Enterprise Cr. No., #118

Temecula, CA 92590

Case History

• Child's Name *

• Birthdate *

• Father's Name *

• Mother's Name *

• Address *

• City, State

• ZipCode *

• E-Mail Address *

• Daytime Phone *

• Cell Phone *

• Doctor's Name *

• Doctor's Phone *

• Child Lives With (check one) *

  Birth Parents   Foster Parents   One Parent   Adoptive Parents   Parent and Step Parent   Other

• Other children In Family

• Other Children in Family

• Child's Race/ Etnic Group

  Caucasian, Non-Hispanic   Native American   Hispanic   Asian or Pacific Islander   African- American   Other

• Other Language Spoken than English at Home *

• If yes, which one? *

• Does Child speaks Language

  yes   No

• Does Child Understand Language

  yes   no

• Who Speaks Language

• Preferable language for Child at Home

• Do you feel your child has a speech Problem

  yes   no

• If yes, please describe.

• Do you feel your child has a hearing problem

  yes   no

• If yes, please describe.

• Has he/she ever had a speech evaluation/screening?

  yes   no

• If yes, where and when

• What where you told.

• Has he/she ever had a hearing evaluation/screening?

  yes   no

• If yes, where and when

• What where you told

• Has your child ever had speech therapy?

  yes   no

• If yes, where and when?

• What was he/she working on?

• Has your child received any other evaluation or therapy (physical therapy, counseling, occupational therapy, vision, etc.)?

  yes   no

• If yes, please describe

• Is your child aware of, or frustrated by, any speech/language difficulties?

• What do you see as your child’s most difficult problem in the home?

• What do you see as your child’s most difficult problem in school?

• Was there anything unusual about the pregnancy or birth?

  yes   no

• If yes, please describe

• How old was the mother when the child was born?

• Was the mother sick during the pregnancy?

  yes   no

• If yes, please describe

• How many months was the pregnancy?

• Did the child go home with his/her mother from the hospital?

  yes   no

• If child stayed at the hospital, please describe why and how long.

• Has your child had any of the following?

  Adenoidectomy   Allergies   Breathing Difficulties   Chicken Pox   Colds   Ear Infections   Ear Tubes   Encephalitis   Flu   Head Injury   High Fevers   Measles   Meningitis   Mumps   Scarlet Fever   Seizures   Sinusitis   Sleeping Difficulties   Thumb/Finger sucking habit   Tonsillectomy   tonsillitis   Vision Problems

• Other serious injury/surgery:

• Is your child currently (or recently) under a physician’s care?

  yesno

• If yes, why?

• Please list any medications your child takes regularly:

• Please tell the approximate age your child achieved the following developmental milestones:

• Sat Alone

• Babbled

• Put two words together

• Walked

• Grasped crayon/pencil

• said first words

• Spoke in short sentences

• Toilet trained

• Does your child...

  choke on food or liquids?   currently put toys/objects in his/her mouth?   brush his/her teeth and/or allow brushing?

• Does your child...

  repeat sounds, words or phrases over and over?   understand what you are saying?   retrieve/point to common objects upon request (ball, cup, shoe)?   follow simple directions (“Shut the door” or “Get your shoes”)?   respond correctly to yes/no questions?   respond correctly to who/what/where/when/why questions?

• Your child currently communicates using...

  Body Language   sounds (vowels, grunting).   words (shoe, doggy,up).   2 to 4 word sentences   sentences longer than 4 words   Other

• Behavioral Characteristics:

  cooperative   attentive   willing to try new activities   plays alone for reasonable length of time   Separation difficulties   easily frustrated/ impulsive   stubborn   restless   poor eye contact   easily distract/short attention   destructive/aggressive   withdrawn   inappropriate behavior   self-abusive behavior

• Name of school and grade in school:

• Teacher's name

• Has your child repeated a grade?

• What are your child’s strengths and/or best subjects?

• Is your child having difficulty with any subjects?

• Is your child receiving help in any subjects?

• Additional Comments

This authorization allows the agency listed below to release to Nichols Speech and Language Services confidential information which may contain protected health information including medical, psychiatric, psychological, mental health, social, legal, drug and/or alcohol abuse, educational, speech or therapy information for inclusion in their records for the purpose of assessment, consultation, case management, service authorization, determining eligibility, planning for services and benefits for individuals with developmental disabilities.

Please click on link fill out form, Sign and mail back to us.

Authorization to obtain Confidential/ Protected Health Information

This authorization allows the agency listed below to release to Nichols Speech and Language Services confidential information which may contain protected health information including medical, psychiatric, psychological, mental health, social, legal, drug and/or alcohol abuse, educational, speech or therapy information for inclusion in their records for the purpose of assessment, consultation, case management, service authorization, determining eligibility, planning for services and benefits for individuals with developmental disabilities.

Please click on link fill out form, Sign and mail back to us.

Authorization to Release Confidential/ Protected Health Information