Revised 7.15.15
California State University, Fresno
Speech, Language and Hearing Clinic
5310 North Campus Drive M/S PH 80
Fresno, California 93740-8019
(559) 278-2422 Fax (559) 278-5187
CHILD CASE HISTORY
PLEASE PRINT IN INK OR TYPE ALL INFORMATION
General Information: Today’s Date: _________________
DiagnosticPlease Check One: Hearing Evaluation Individual Speech Therapy
PUPS Preschool SEALS Preschool STARS Preschool
Child’s Name: ________________________________ Date of Birth:
____________ Gender: __________
Address
: __________________________________ City:
____________________ Zip: _________________
Mother’s Name: __________________________________________
Age:__________________________
Mother’s Occupation: ______________________________________
Home Phone: ___________________ Cell Phone: _______________
Work Phone: __________________
Father’s Name: ___________________________________________
Age:__________________________
Father’s Occupation: ______________________________________
Home Phone: ___________________ Cell Phone: _______________
Work Phone: __________________
Does the child live with both parents? _________________________________________________________
Emergency Contact Name: _________________________________
If no, with whom does the child live? __________________________________________________________
Home Phone: ___________________ Cell Phone: _______________
Work Phone: __________________
Referred By: __________________________________________
Phone:___________________________
Physician: _____________________________________________
Phone:___________________________
Address: __________________________________________________________________________________
Office Use Only:
Date Received: ____________________________________________________________________________
Dates Contacted: ___________________________________________________________________________
Relationship: __________________
Brothers and Sisters (include names and ages): ___________________________________________________
Email:__________________________
Email:
__________________________