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Client & Parent Details

If you have an email invitation with your client ID and case ID, please fill in that information below

Client ID

Case ID

Client Details

First Name

Last Name

Mailing Street (including Apartment/Suite)

City

State/Province

Postal Code

Country

Mobile Phone

Client's Email

Native Language of Client

Date of Birth

Referred by:

Referred by Other:

School Child Currently Attends

Pediatrician/PCP Name, Phone, and Address

Parent/Guardian 1 Details

Please enter details about the Parents/Guardians of the Child separately. Please enter details below about the primary parent, or the parent who is filling out this application.

Parent/Guardian 1 Relationship to Child

Biological ParentAdoptive ParentLegal GuardianGrandparentOther

Parent/Guardian First Name

Parent/Guardian Last Name

Custody of Child

Currently married to the child's other legal guardianSole Custody of the childPrimary Custody of the childJoint/Shared Custody of the childNo Custody of child

Does your child have any contact with the other parent? Please explain.

Mailing Address:

Same as ChildI would like to enter a different mailing address

Mailing Street (including Apartment/Suite)

City

State

Postal Code

Mobile Phone

Home Phone

Work Phone

Preferred Phone

Date of Birth

Highest Grade Completed

Employer Name

Parent/Guardian 2 Details

Please enter details about Parent/Guardian 2 of the Client

Parent/Guardian 1 Relationship to Child

Biological ParentAdoptive ParentLegal GuardianGrandparentOther

Parent/Guardian First Name

Parent/Guardian Last Name

Custody of Child

Currently married to the child's other legal guardianJoint/Shared Custody of the childNo Custody of child

Mailing Address:

Same as ChildI would like to enter a different mailing address

Mailing Street (including Apartment/Suite)

City

State

Postal Code

Mobile Phone

Home Phone

Work Phone

Preferred Phone

Date of Birth

Highest Grade Completed

Employer Name

Family History

Does your child have siblings?

YesNo

Please list their names and ages:

How does your child get along with siblings?

During family conversations, how does your child manage?

Page 2

Client Speech & Language History

Please describe your child's current speech and language skills and any concerns you may have

What was the approximate age at which your child began having difficulty with speech fluency (stuttering)?

Select all that apply:

My child has attended speech therapy previously.My child is currently enrolled in speech therapy

If your child has attended speech therapy previously, please describe the experience:

If your child is currently enrolled in speech therapy, what is the purpose of their current treatment?

Please describe your child's stuttering when it first began (select all that apply):

repetitions of first letters (b-b-boy) repetitions of whole words (boy-boy-boy) repetitions of parts of words (ca-ca-cat) prolongations of sounds (mmmmmom) silent blocks before speaking (-----boy) fillers (um, well, uh) changing words or starting overother (please describe)

Other intiial stuttering description

Please describe your child's stuttering currently (select all that apply):

Other current stuttering description

Please describe your child's initial accompanying behaviors (select all that apply):

eye blinkingsqueezing eyes shutlooking awayhead noddinghand or foot movementdifficulty breathingother (please list)

Other initial accompanying behaviors

Please describe your child's current accompanying behaviors (select all that apply):

eye blinkingsqueezing eyes shutlooking awayhead noddinghand or foot movementdifficulty breathingother (please list)

Other current accompanying behaviors

My child is aware of their stuttering:

YesNoI don't know

How does your child react to their stuttering (i.e., awareness, frustration, shame, indifference, avoidance)?

Are there any situations where your child appears to stutter more often? Please explain.

Are there any situations where your child appears to stutter less often? Please explain.

My child's stuttering...

Is fairly consistent in most situationsFluctuates depending on situation

Do you have any other speech/language concerns for your child? If so, please explain.

Page 3

Medical and Developmental History

Has your child had any health problems? Please explain.

Does your child have any hearing problems? Please explain.

Please list any current or past physical disabilities

Has your child received (select all that apply):

Physical TherapyOccupational Therapy

What was the purpose of the therapy above?

Has your child had a history of ear infections?

YesNo

Please provide details (# of times per year, ages)

Does your child take medication?

YesNo

Please provide details (medication name, purpose, dosage)

Please select all that apply (it is helpful to ask spouse/relatives about a possible history of stuttering)

One parent has stuttered but no longer stuttersBoth parents have stuttered but no longer stutterOne parent stutters currentlyBoth parents stutter currentlyOne parent had therapy for stutteringBoth parents had therapy for stutteringNeither parent has stutteredA family member has stuttered but no longer stuttersA family member stutters currentlyA family member had therapy for stutteringInformation about the child's biological family stuttering history is unavailable

Compared to other children, how sensitive is your child in general?

When your child becomes upset, are they able to calm down easily (on average)?

Compared to other children, how fearful is your child in general?

Page 4

Educational & Social History

Grade Child is Currently In

Do you have concerns about the child's current school situation, or are any changes planned?

What feedback do you get from the child's teachers and school staff?

IEP - Please select all that apply:

My child currently has an IEP (Individualized Education Plan) at schoolMy child has previously had an IEPMy child has 504 or other accommodations agreed to by the school

Please provide details about the child's current accommodations and services they are receiving from school

Teachers appear to be concerned about my child's stuttering

YesNoI don't know

How do teachers react to your child's stuttering?

Page 5

Client Demographic Information

Gender

Pronouns

Race

Other Pronoun

Ethnicity

Consent & Electronic Signature

I give permission for the American Institute for Stuttering (AIS) to observe and videotape me and/or my child (if client is minor) under the supervision of their clinician, by treatment staff, and/or interns. The purpose of this observation is to advance the education and treatment of those who stutter

I agreeI do not agree

Statement and Certification:

I verify that all of the information I have provided is true and correct to the best of my knowledge.I adopt the electronic signature provided below by typing my name.I give permission for American Stuttering Institute to contact me regarding the services I've requested.

Client Full Name

Parent or Guardian Electronic Signature

Please type your full legal name

Date of Electronic Signature

Please enter today's date

Financial Assistance

I would like to apply for financial assistance through AIS to help pay for my child's treatments.

YesNo

Teen Self-Report Survey

This form is intended for the client to fill out. Please have your teen fill out this self report survey and do not fill it out on their behalf. If you need to, you may save the form and resume later.

Please read each statement and select the choice that most closely matches how the statement applies to you.

Name of Person Filling this Form

I avoid some situations and conversations because I stutter