Adolescent/Teen Case History Form

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Client & Parent Details

Client Details














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 2 Details
Please enter details about Parent/Guardian 2 of the Client

















Family History




Page 2

Client Speech & Language History



















Page 3

Medical and Developmental History













Page 4

Educational & Social History







Page 5

Client Demographic Information





Consent & Electronic Signature




Please type your full legal name

Please enter today's date
Financial Assistance

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.