Child Case History

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

Minor Client Details

First Name

Last Name

Mailing Street (including Apartment/Suite)

City

State/Province

Postal Code

Country

Native Language of Client

Date of Birth

Referred by:

Referred by Other:

School Child Currently Attends

Pediatrician Name, Phone, and Address

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 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