It Takes Two to Talk® -

The Hanen Program@ for Parents of Children with Language Delays

General lnforniation Forni

Date: --------------

Child's name: -----------

Date of birth (dd/mm/yy): ____ _

Mother's name: Father's name: ------------

Address: ---------------------------------

Phone: (home) ----------

(mother work) ------------

(father work) -----------

Mother's occupation: ______ _ Father's occupation: _________ _

Family doctor/pediatrician: _____________________ _

Siblings: ____________________________ _

In which language do you speak to your child most/all of the time? _____ _

In which language do you speak to your spouse/partner? __________ _

Child's day-care centre/preschool: __________________ _

Medical diagnosis (if applicable) (ASD, cerebral palsy, hydrocephalus, Down syndrome,seizures, etc.):

-------------------------------

Medical history (please provide any significant information regarding your child's birth,

health during infancy, allergies, seizures, hospitalizations, etc.) -------------

Does your child have a history of hearing difficulties? D Yes D No

Results of latest hearing tests: -----------------------

U The

I © Hanen Early Language Program, 2017. This handout from the "Making Hanen Happen Leaders Guide for It Takes Two to Talk®

Hanen (Conklin, Weitzman, Pepper & McDade, 2017)" may be copied for clinical purposes and for use in full or approved adapted It Takes Program• Two ta Talk Programs by speech-language pathologists with It Takes Two to Talk certification and current Hanen membership.

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Date: Childs name: Date of birth ddmmyy: Fathers name: Address: Phone home: mother work: father work: Mothers occupation: Fathers occupation: Family doctorpediatrician: Siblings: In which language do you speak to your child mostall of the time: In which language do you speak to your spousepartner: Childs daycare centrepreschool: seizures etc: health during infancy allergies seizures hospitalizations etc 1: health during infancy allergies seizures hospitalizations etc 2: Results of latest hearing tests: When and where were these tests done: Has your child had any ear infectionscongestion requiring medication andor tubes: Does your child have any visual difficulties Yes No: When and where were these tests done_2: Please describe any difficulties in walking playing with toys feeding himherself: iour extreme shyness etc Yes No: Please explain: Date 1: Date 2: Name of personagency 1: Name of personagency 2: Commentsresults 1: Commentsresults 2: 1: 2: 1_2: 2_2: 1_3: 2_3: Date 1_2: Date 2_2: Name of personagency 1_2: Name of personagency 2_2: Commentsresults 1_2: Commentsresults 2_2: undefined_4: undefined_5: undefined_6: When did you become concerned about your childs communication: undefined_7: Crawling: Walking: Feeding himherself: Toilet training: Dressing himherself: Explains to other children what to do in a game: undefined_9: Favourite activities at home: Additional comments 1: Additional comments 2: undefined_10: Onestep directions eg Go and get your shoes: undefined_11: Twostep directions eg Put your coat on and wait by the door: Complex directions eg When you are finished eating you can play outside: undefined_12: What questions eg What are you doing Whats that: undefined_13: Who questions eg Whos at the door: undefined_14: Where questions eg Wheres your car 1: Where questions eg Wheres your car 2: Why questions eg Why are you crying 1: Why questions eg Why are you crying 2: Other questions 1: Other questions 2: Other: Additional comments: 1_4: 2_4: 1_5: 2_5: 3: 4: Completed by: Date_2: Date_3: undefined_15: Date_4: Check Box1: OffCheck Box2: OffCheck Box3: OffCheck Box4: OffCheck Box5: OffCheck Box6: OffCheck Box7: OffCheck Box8: OffCheck Box9: OffCheck Box10: OffCheck Box11: OffCheck Box12: OffCheck Box13: OffCheck Box14: OffCheck Box15: OffCheck Box16: OffCheck Box17: OffCheck Box18: OffCheck Box19: OffCheck Box20: OffCheck Box21: OffCheck Box22: OffCheck Box23: OffCheck Box24: OffCheck Box25: OffCheck Box26: OffCheck Box27: OffCheck Box28: OffCheck Box29: OffCheck Box30: OffCheck Box31: OffCheck Box32: OffCheck Box33: OffCheck Box34: OffCheck Box35: OffCheck Box36: OffCheck Box37: OffCheck Box38: OffCheck Box39: OffCheck Box40: OffCheck Box41: OffCheck Box42: OffCheck Box43: OffCheck Box44: OffCheck Box45: OffCheck Box46: OffCheck Box47: OffCheck Box48: OffCheck Box49: OffCheck Box50: OffCheck Box51: OffCheck Box52: OffCheck Box53: OffCheck Box54: OffCheck Box55: OffCheck Box56: OffCheck Box57: OffCheck Box58: OffCheck Box59: OffCheck Box60: OffCheck Box61: OffCheck Box62: Off