Important Case History Information for a Telepractice Evaluation

As a telepractitioner, it can be difficult to gather information about a student/client because of working remotely.  It isn’t as easy as walking down the school hall to obtain the teacher’s input or calling the parents to obtain the information. I cannot count the times I have called parents to ask “case history” type questions but was sent directly to voicemail.  I am not surprised they do not answer. Afterall, how many of us answer our phones when we don’t recognize the area code much less the number?

I recommend looking around online to gather free case history forms, and go through each, highlighting the questions you feel are most applicable while crossing out the ones that are not.  Next, I begin pulling together the questions in a WORD document to generate a case history form that meets my needs. The tricky part is asking for the information you need to provide a complete picture of the student without overwhelming the parents with pages of questions.  Parents respond well to checklists with space to write in additional information. When generating a case history form, I incorporate a variety of answer-types, allowing space for parents to elaborate on items if they so choose.

I begin by asking for demographic information, including names and ages of parents and siblings as well asking if any have experienced Speech/Language difficulties.  Next, I ask about parental and birth history:  length of pregnancy, length of delivery, birth weight of baby, any pregnancy or delivery complications for the mother, any type of nursing difficulties. Then I move onto the student’s medical history asking about any surgeries, injuries requiring hospitalization (i.e., traumatic brain injury), or seizure disorders.  Has the student been given any type of medical diagnosis? Is the student currently taking any medication (including over-the-counter)?  What about hearing concerns? Has the child experienced ear infections and if so, how often? Tubes?  Does the student have any visual difficulties? Does h/she wear glasses/contacts?

The next section asks for developmental information about the student.  A checklist with cognitive, as well as communication, skills works well here as many parents do not recall the exact ages their student could sit, stand, walk.  Asking parents to check the boxes next to the skills their student could perform (with the ages provided) seems to provide more information about the student’s developmental history versus asking, “At what age did your child…” Include items that ask if the student: crawled by 12 months, first walked around 16 months, sat alone by 12 months, was toilet trained by 3 years, was googling/babbling by 4 months, said 2 words together by 24 months, and produced short sentences by 36 months.

I also include a behavioral history section, asking the parents to circle the items that describe their child: friendly, impulsive/impatient, easy-going, separation difficulties, uses eye contact, hyperactive, sleeps well, has temper tantrums, willing to try new activities, avoids touching certain textures, restless, shy, cries easily, and other behaviors that could impact a student’s academic performance.  This list should not be exhaustive but include enough items to provide a solid view of the student’s temperament. The final section includes educationally relevant information. Is the student currently receiving any Special Education services? If so, does your student have an IEP? How are the student’s grades?  How well does he/she get along with classroom peers? Does he/she have difficulty following school rules?

Lastly, I ask the student’s teacher(s) to complete a “Communication Skills” inventory because what we may observe while working with students during therapy may be completely different than the communication skills students demonstrate within the classroom setting. This works well to identify areas that may need to be evaluated and included in the assessment plan.

I tend to send out the forms when I send the parents the “Consent for Assessment” form.  Be sure to include the date the forms should be returned by, as well as the name of the person the forms should be returned to, on each, so they do not get lost in the shuffle. The information offered may provide insight into the assessments you want to use along with other considerations such as necessary rapport-building with the student before beginning the assessments and whether-or-not the student benefits from breaks during the evaluation.

It can be difficult to develop a well-rounded description of a student when working with him/her remotely.  Assessing a student via telepractice requires some additional “footwork,” such as asking parents/caregivers to complete a case history form as well as having the teacher complete a questionnaire about the student’s communication skills in the classroom.  Gathering background information on a student you will be assessing via telepractice is critical to developing a representative picture of the student’s current communication skills.

TPT Supporting Resources:

Disfluency Case History Form
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