Communication Innovation, Inc.
Shani K. Romick, MS CCC/SLP
Confidential Case History Form
*Please complete & return before your first appointment*
Today’s Date:____/____/__
Patient Information:
Name: ______Likes to be called:______
Date of Birth:______Age:_____
Street Address:______City/State/Zip code:______
Home Telephone:______Cell: ______
Email:______
Main language used:______other languages?:______
Employer or school and grade if student:______
Name of Primary Physician:______Telephone:______
Name of Counseling Professional: ______Telephone:______
Has the patient had any psychological, educational or Speech Language Pathology Testing?:
Describe:______
Existing Medical/psychological, etc. Diagnosis(es):______
Referred by (if any):______
What services are you seeking today?: ______
Have you received treatment for this concern previously? If yes, when/where/results:____
______
______
Please describe your main concern/problem:______
______
Who notices this problem the most?:______
How long have you had this difficulty?:______
What do you think may have caused the problem?:______
How has the difficulty changed over time?:______
Describe the effects of your difficulty in the following areas:
At school/work:______
At home/with family:______
In social situations:______
Please list 2-3 goals/skills you would like to see improve with therapy:
______
______
______
Please share a few of your/your child’s favorite activities/interests:
______
Do you have a hearing loss, vision problem, learning disability or a speech/language disorder?:
(circle all that apply) please describe:
______
Do you have any food allergies?List:______
Have you had a stroke, head injury or other neurological problem?_____
Describe:______
Other problems not previously listed:______
Current Medications/what are they taken for:______
______
Describe any relevant concerns or issues which you have not written about:______
______
______
Person completing this form:______Relationship to patient:______
If patient is a minor:
Name and contact information of parents/legal guardians:______
Parent’s marital status:______
Patient lives with:______
Any custody situations you would like me to be aware of?:______
Emergency Contact
Name:______Relationship:______
Phone numbers:______
Family Information
List all persons living with the patient and siblings living elsewhere:
NameAge Relationship/living at home?
______
______
______
______
______
Indicate any significant stressors or changes the patient/family has experienced in the last year:
____ death of a family member___marital stress/tension____financial stress
____change in residence ____change of school/job ____legal problems
____job or school problems
_____addictions/alcohol or drug use ___other:______
Thank you for completing this form. The information will help me provide the best service for you and your family.
Shani Romick MS CCC/SLP 4608 Yorkshire Trail Plano, TX75093 972-754-1234
Please note: I value your time and I will be prompt for our appointments. Please extend the same courtesy to me.
Appointments will end at their scheduled time so that the appointment after yours starts on time.
Please call me if you are running late and give me 24 hours for a cancellation to avoid charges.
Please submit payment (check or cash) at the time of service.
Thank you.
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