Parent Interview - Richland Parish School Board
Parent Interview for Initial Speech/Language Evaluation
Your child’s full name __________________________ Birth date:__________
Name of person filling out this form____________________________
History of Pregnancy and Birth:
During this pregnancy, did the mother experience and unusual illness, condition or accident, such as German measles, false labor, or Rh incompatibility. If so, describe:
Length of pregnancy: Duration of labor _____ Birth weight ________
Unusual conditions at or immediately after birth:
Did the infant have: Feeding problems _________ Seizures_________
Development:
Did your child walk, run, sit-up at normal ages? ____________
About how old was he/she when toilet trained? ____________________
Does he/she seem awkward, uncoordinated? __________________________
Does he/she have difficulty chewing or swallowing?______________
Medical, Social, Educational:
Is your child in good health at this time? List any physical or medical handicaps:____________________________________________________
_____________________________________________________________
Speech Development:
About what age did your child say ma-ma or daddy?
When did he start using sentences or putting words together?
Did speech development ever seen to stop for a period?
Has there been a change in his/her speech in the last six months?
Does he seem to be aware of his/her speech difference?
What efforts have been made to help him/her talk better?
Do others tease the child about his speech?
What is his reaction to his speech?
Has the child had a prior speech or hearing examination?
If so, please state when the examination was given, by whom, and for what reason:_________________________________________________________
_______________________________________________________________
If there is additional information, which you feel, will help us to understand your child better, please describe:
................
................
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