Free speech therapy template

Speech therapy case history form and format

A speech therapy case history form for children and adults, in an open-question format, with sample answers to guide you.

Separate child and adult sections
Records every language at home
Open questions, no milestone checklists

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What's inside

About the Person
Languages and Communication at Home
Main Communication Concerns
Hearing History
Health and Medical History
Feeding, Eating and Swallowing (as Reported)
For Children: Early History and Play
For Adults: Onset and Daily Life

+ 4 more sections

Speech and Language Case History Form

Name		Date of birth
Date completed		Completed by (relationship)
Referred by		Preferred contact (phone / WhatsApp / email)

About the Person

Name the person likes to be called

Who lives at homeInclude grandparents, other relatives and regular carers.

School, college or workName, class or role, and the language of teaching or work.

Languages and Communication at Home

Language	Who uses it with the person	Does the person understand it?	Does the person speak it?

Language preferred for therapy, if any

Main Communication Concerns

What concerns you most about communication?

When did you first notice this, and has it changed?

Who else has raised a concern (teacher, doctor, relative)?

What helps, and what makes it harder?

Hearing History

Hearing tests: when, where, and what you were told

Ear infections, ear discharge or ear surgery, as reported

Hearing aids or other devices, and how often they are used

Health and Medical History

Medical conditions, hospital stays or surgeries

Medicines taken regularly

Other professionals currently involved

Feeding, Eating and Swallowing (as Reported)

Any past difficulties with feeding, chewing or moving to new foods

Any coughing, choking or very long mealtimes now

For Children: Early History and Play

Anything you would like us to know about pregnancy and birth

How did your child first communicate? Describe it in your own words

How does your child play and interact with other children and adults?

For Adults: Onset and Daily Life

What changed, and when did you notice it?

How does this affect work, family life and social activities?

Strategies, aids or devices already used

Previous Assessments and Therapy

Service or professional	When	What was done	Report available?

Family and Client Priorities

What would you most like to change in the coming months?

Best days and times for sessions

Permission to Contact Others

I agree that the therapist may contact the school or teacher named above
I agree that the therapist may contact the doctor or other professionals named above
I would like reports sent to me by email or WhatsApp

Therapist Sign-off

Therapist	Designation	Registration	Date

How to fill it in

About the Person
Preferred name, who lives at home, the main carer, and school or work.
More guidance
Ask for the name the person likes to be called and who lives at home. In joint families the main daytime carer may be a grandparent or aunt, and that person's language and availability will shape therapy. Ask about school or work early, including the language of teaching.
Languages and Communication at Home
Every language the person hears or uses, who uses it, and what they understand.
More guidance
List every language the person hears or uses, who uses it with them, and whether they understand and speak it. Never assume the language of the form is the language of the home. This table is the most important context you will have when you interpret later findings.
Main Communication Concerns
The concern in the family's words, when it began, and what helps.
More guidance
Let the family describe the concern in their own words, and keep their wording where you can. Ask when it was first noticed and whether it has changed, who else is concerned, and what makes it better or worse. These answers become the first lines of the reason for referral in your assessment report.
Hearing History
Hearing tests, ear problems and devices, recorded exactly as the family reports.
More guidance
Ask about hearing tests, ear infections, discharge, surgery and devices, and record the answers exactly as given, including what the family was told about results. Many families are unsure. "Don't know" is a useful answer, because it tells you a hearing test may be needed before you interpret other findings.
Health and Medical History
Conditions, hospital stays, medicines and the other professionals involved.
More guidance
Ask about conditions, hospital stays, surgeries and regular medicines through open questions, and list the other professionals involved, such as a paediatrician, neurologist, occupational therapist or special educator. Record their names so you can request reports with the family's consent.
Feeding, Eating and Swallowing (as Reported)
Feeding past and present as reported; use your referral pathway for safety concerns.
More guidance
Ask simple questions about feeding past and present: breast or bottle, chewing, accepting new textures, coughing or choking, and how long meals take. Record what the family reports. If an answer suggests a swallowing safety concern, follow your clinic's referral pathway rather than relying on the form.
For Children: Early History and Play
Pregnancy, birth and early communication in the parents' own words, not ages.
More guidance
Ask parents to describe pregnancy, birth and early communication in their own words instead of ticking milestones against ages. Open questions such as "How did your child first let you know what they wanted?" bring richer and more reliable answers than trying to recall exact months.
For Adults: Onset and Daily Life
What changed, when, and how it affects work, family and social life.
More guidance
Ask what changed, when, and how quickly, then how it affects work, family and social life. Include the client's own goals for returning to roles such as teaching, running a shop or speaking at family events. Note any aids or strategies already in use.
Previous Assessments and Therapy
Earlier assessments and therapy: who, when, what was done, and any report.
More guidance
List each earlier assessment or block of therapy: who, when, what was done, and whether a report exists. Ask the family to bring copies. Earlier reports help you avoid repeating a test too soon and show you what has already been tried.
Family and Client Priorities
What the family or client most wants to change, quoted with who said it.
More guidance
Finish with what the family or client most wants to change. The priorities recorded here should appear again in the assessment report and the treatment plan, so keep them in the family's own words. If parents and grandparents give different priorities, record each one with who said it.
Permission to Contact Others
Optional consent tick boxes, explained to the family, supporting your clinic's own policy.
More guidance
The tick boxes record what the family agrees to at intake. Explain each one, make clear that every box is optional, and remind the family they can change their mind later. Follow your clinic's own consent policy; this checklist supports it and does not replace it.

Speech therapy case history form and format: filled sample

Fictional entries, initials only, showing the level of detail to aim for. Impression and summary sections are left for the treating clinician.

About the Person

Lives with parents, paternal grandparents and an older sister. Grandmother looks after K. on weekdays. Attends UKG in an English-medium school.

Languages and Communication at Home

Main Communication Concerns

"She talks a lot but only we understand her. At school she has stopped putting her hand up." (mother)

Hearing History

Newborn hearing screen done in hospital; parents were told it was "fine". Frequent colds with ear pain last winter; no hearing test since.

Health and Medical History

Admitted for jaundice for three days after birth, as reported. Sees a developmental paediatrician every six months and attends occupational therapy weekly.

Feeding, Eating and Swallowing (as Reported)

Mother reports R. still prefers soft foods such as rice and dal mixed together and gags on pieces of chapati. No coughing at meals reported.

For Children: Early History and Play

"He pointed and pulled us to things. Words came later, first in Tamil." Enjoys stacking blocks with his cousin; prefers to play alone at school.

For Adults: Onset and Daily Life

Mr S. reports that his speech became slurred after a stroke in March. He has stopped answering the phone at his shop and asks his son to speak to suppliers.

Previous Assessments and Therapy

Private speech therapy clinic, last year | 10 sessions | "Sound practice" | Report at home, family will bring it

Family and Client Priorities

"I want my mother-in-law to understand him when I'm at work." (mother)

Paediatric vs adult case history

	Paediatric sections	Adult sections
Who answers	Parents, grandparents or other carers	The client, sometimes with a spouse or grown-up child
History focus	Pregnancy, birth, early communication and play	Onset, how quickly things changed, and daily life
Setting questions	School, class and the teacher's concerns	Work, family roles and social activities
Languages	Languages at home, at school and with each carer	Languages used at work, at home and in the community
Priorities	What the family wants to change	What the client wants to return to or keep doing

Tips and mistakes to avoid

Do

Send the form before the visit as a phone-friendly PDF, or let families answer aloud while you write.
Go through it with the family; how a parent answers often tells you as much as the words.
Keep "as reported" in the hearing and feeding sections, since the history records what families tell you.
Delete the child or adult section before sending, so families see only relevant questions.
In healhab, the completed history can sit in the patient's document repository beside the assessment report.

Avoid

Adding milestone checklists with ages, which turns the form into a test parents feel they are failing.
Asking only about English and missing the language the child speaks with grandparents.
Leading questions such as "Did your child talk late?" in place of open ones.
Not recording who completed the form, when parents and grandparents may give different accounts.

About this case history form

A speech therapy case history form collects background before the first assessment: who the person is, the languages used at home, the main communication concerns, hearing and health history, feeding as reported, earlier assessments and the family's priorities. This format has separate sections for children and adults, and it asks open questions only, so families answer in their own words.

Before a first speech and language assessment
A family self-refers by phone or message
Re-opening a case after a long gap
Adults referred after a stroke, surgery or voice change

The case history is where an assessment begins. It tells you which languages to plan for, whether a hearing test is on record, and what the family hopes will change.

Families fill it in before the first visit, and you go through it together. It asks open questions only and lists no milestone ages, because age checklists push parents to guess.

Questions

What is a case history in speech therapy?

The background collected before or at the start of an assessment: concerns, languages, hearing, health, feeding, early history or onset, previous therapy and priorities. It guides what you assess and how you interpret the results.

What is the case history format for speech therapy?

Identifying details and the main concern, then languages, hearing, medical history, feeding, early history or onset, school or work, previous services and priorities. This form follows that order, with separate child and adult sections.

Is there a filled sample of this case history?

Yes. Most sections show a fictional sample answer, using initials only, to show the detail worth recording. The form gathers reported history only; your interpretation belongs in the assessment report you write afterwards.

Why does the form not list developmental milestones?

Milestone lists with ages invite parents to guess dates they may not remember and can cause unnecessary worry. Open questions give more useful answers, and you can explore development in your clinical interview.

Can I use the same form for children and adults?

Yes. The form has a section for children and one for adults. Delete the section that does not apply before you send it.

Is a case history the same as an intake form?

They overlap. An intake form often adds practical details such as fees and appointment preferences, while a case history concentrates on communication and health background. Many clinics combine the two.

More speech therapy templates

Case history form formats for other therapies

Write every report inside your clinic system.

Keep these as your clinic's own templates, write from reviewed session notes, publish branded PDFs, and keep families updated.

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