SPH511 Categorisation of client information following Case History Interview SIM
Georgia Copeland; Master of SP student
Body Structure & Function
*June reports the following
developmental Hx:
~ a healthy pregnancy with Michael,
born at 42/40
~ Michael was exclusively bottle-fed
with formula; started solid foods at
6/12
~ typical motor skills development with
sitting at 6/12, walking at 12/12
~ first words spoken at 12/12
*June reports a recent optometrist
consult and Dx of mild astigmatism
(items are perceived on an angle);
reading glasses have been prescribed
and ordered but are not yet available
on 25/08/22
*June reports left arm Fx recently; cast
still on; left-handed; no OT to date
*June reports that father and paternal
uncle self-report as having reading
difficulties; no formal dyslexia Dx
*June reports that Michael’s mental
state as “optimistic” and emotional
state as “sometimes frustrated”
Activities & Participation Environmental Factors Personal Factors
*June reports early literacy exposure as ~ Michael lives with mother (June), *June attended appointment on 25/8
reading storybooks to Michael; Michael father (Simon), sister (Sarah) and
*June reports and confirms:
was able to watch and listen but not his dog (Marmalade)
~Michael is a 9;0 male school student in
engaged with pointing to parts of
Grade 3
words *Michael’s teacher Mr Smithers
~ 2022 teacher is Mr. Smithers
offered support through this
*June did not have specific data about ~ Michael is brother to one sibling, Sarah
referral to SP services
Michael’s literacy progress from
*June reports she would like some further
F-Grade 3 during initial interview
*June reports that Michael’s school information about Michael’s literacy
*June reports that Michael participates
has some literacy support available difficulties and would like to learn some
in school’s reading support program,
and mentioned phonics based strategies to support Michael to catch up to
after school
intervention his peer group
*Mr Smithers’ written referral states
*Requested that June make a follow-up
general reading difficulty, handwriting *June reports that Michael’s
appointment in 2/52 and Michael attend with
difficulty and inconsistent friends have recently teased him
June
sound-to-letter construction with because his reading and writing is
spelling attempts not at similar levels to theirs *Requested permission from June to contact
Mr Smithers’ for specific literacy data; June
*June reports Michael is “very active”
*Audiologist Ax booked for 09/22 consented
and “outgoing”; he enjoys playing team
sports (soccer, football, hockey), *Offered email and phone contact to June
*Plan: to ask if Michael has ever
jumping on the trampoline, and playing before next appointment; if she has further
accessed any products or
with his dog (Marmalade) questions or data
technologies to assist with learning
*June reports no noticeable difference literacy or literate behaviours *Plan: continue to ask June and Michael
in Michael’s home life or behaviour, but questions about handwriting difficulties once
Mr Smithers has told her of “acting out his cast comes off; suggest OT referral;
in class” consult with Mr Smithers

SPH511 Categorisation of client information following Case History Interview SIM:
Body Structure & Function ▲
*I will be asking specific questions
about Michael as we chat but to
begin, how would you describe
Michael’s general development
from birth to pre-school?
*Learning is closely linked to
hearing, vision and our fine motor
skills. May I have the details of any
hearing tests or eye tests, or even
any motor skills assessments with
an OT if Michael has ever had one
of those?
*Thinking of family health history,
please tell me any details that
could be important to help us with
Michael’s learning?
*How do you think Michael might
be feeling about himself at the
moment? b152 ▲ ↔ ⚈ 🖤 behaviour changes. What can you
Activities & Participation ↔
*Please tell me about Michael’s
school learning journey so far. You
might like to think from
kindergarten or Prep and the years
in between, or perhaps there are
some ‘lightbulb’ moments that
come to mind.
*I would like to hear some details
of some literacy interventions that
Michael might have done?
d820 & e585: ↔ + ⚈
*I would love to hear about
Michael’s passions. Can you please
tell me some things that he likes to
do, and things that motivate him?
*I am wondering if Michael might
be experiencing any changes in his
life, or demonstrating any
tell me, June?
d3 & d7 & e3: ↔ + ⚈
SPH511 Categorisation of client information following Case History Interview SIM
Environmental Factors ⚈
*Does Michael have any experience
with reading or writing using
technology to help?
*Thinking about Michael’s reading,
handwriting and how he tries to
spell words, what feedback have
you received so far about his
progress?
*Please tell me about other
professionals who may have seen
Michael over the years. Just to get
the ball rolling, there might be a
paediatrician, occupational
therapist, psychologist, audiologist
for hearing, optometrist for
vision… ⚈ + ▲
*How informed do you feel about
the way Michael’s school, his
teachers, teach reading, spelling
and handwriting?
Georgia Copeland; Master of SP student
Personal Factors 🖤
*Hi June, my name is Georgia and I
am a local speech pathologist. I
would like to confirm some details
about Michael, to make sure the
referral information is correct. How
old is Michael, who is in your
family, what grade is Michael in,
and who is his classroom teacher
this year?
*Thanks for coming along and
chatting to me today June. Tell me
about why you are here today…
what do you think I can help
Michael and your family with?
*What else would you like me to
know about Michael’s
development? ▲ ↔ ⚈ 🖤
 SPH511 Categorisation of client information following Case History Interview SIM

Georgia Copeland; Master of SP student

1. Hi June, my name is Georgia and I am a local speech pathologist. I would like to confirm some details about Michael, to
make sure the referral information is correct. How old is Michael, who is in your family, what grade is Michael in, and who
is his classroom teacher this year?

2. Thanks for coming along and chatting to me today June. Tell me about why you are here today… what can I help
Michael and your family with?

3. I will be asking specific questions about Michael as we chat but to begin, how would you describe Michael’s general
development from birth to pre-school?

4. Learning is closely linked to hearing, vision and our fine motor skills. May I have the details of any hearing tests or eye
tests, or even any motor skills assessments if Michael has ever had one of those?

5. Thinking of family health history, please tell me any details that could be important to help us with Michael’s learning?

6. I would love to hear about Michael’s passions. Can you please tell me some things that he likes to do, and things that
motivate him?

7. Please tell me about Michael’s school learning journey so far. You might like to think from Kindergarten or Prep and the
years in between, or perhaps there are some ‘lightbulb’ moments that come to mind.

8. Please tell me about other professionals who may have seen Michael over the years. Just to get the ball rolling, there
might be a paediatrician, an occupational therapist, psychologist… (audiologist for hearing, optometrist for vision; could
have been covered earlier)
 SPH511 Categorisation of client information following Case History Interview SIM

Georgia Copeland; Master of SP student

9. Thinking about Michael’s reading, handwriting and how he tries to spell words, what feedback have you received so far
about his progress?

10. June, can you please tell me the details of any literacy interventions that Michael might have done?

11. Does Michael have any experience with reading or writing using technology to help?

12. How informed do you feel about the way Michael’s school, his teachers, teach reading, spelling and handwriting?

13. I am wondering if Michael might be experiencing any changes in his life, or demonstrating any behaviour changes.
What can you tell me, June?

14. How do you think Michael might be feeling about himself at the moment?

15. What else would you like me to know about Michael’s development? Thank you so much June.
 SPH511 Categorisation of client information following Case History Interview SIM

Georgia Copeland; Master of SP student

Carole, acting as “June” (Michael’s mother)

1. Hi June, my name is Georgia and I am a local speech pathologist. I would like to confirm some details about Michael, to
make sure the referral information is correct. How old is Michael, who is in your family, what grade is Michael in, and who
is his classroom teacher this year? 9 & ½ , father Simon, little sister Sarah is 6 years old, Grade 3, Mr Smithers

2. Thanks for coming along and chatting to me today June. Tell me about why you are here today… what can I help
Michael and your family with?

3. I will be asking specific questions about Michael as we chat but to begin, how would you describe Michael’s general
development from birth to pre-school? Pregnancy information please (full-term, smooth pregnancy), formula-feed baby
from birth, started eating solid food at 6 months, sitting up at 6 months, walking at 12 months, using first few words at 12
months

4. Learning is closely linked to hearing, vision and our fine motor skills. May I have the details of any hearing tests or eye
tests, or even any motor skills assessments from an OT, if Michael has ever had one of those?
~ Optometrist information please (mild astigmatism, glasses coming),
~ Audiology appointment booked for next month,
~ Broke his arm recently and June thinks “maybe he could use some OT or physio to make sure it has healed properly…
but we have not done this yet, not sure about it”

5. Thinking of family health history, please tell me any details that could be important to help us with Michael’s learning?
Father and uncle with dyslexia
 SPH511 Categorisation of client information following Case History Interview SIM

Georgia Copeland; Master of SP student

6. I would love to hear about Michael’s passions. Can you please tell me some things that he likes to do, and things that
motivate him?
~All the sports!
~Jumping on trampoline
~Playing with his dog
~Meeting other kids and joining in happily with all games

7. Please tell me about Michael’s school learning journey so far. You might like to think from Kindergarten or Prep and the
years in between, or perhaps there are some ‘lightbulb’ moments that come to mind.

8. Please tell me about other professionals who may have seen Michael over the years. Just to get the ball rolling, there
might be a paediatrician, an occupational therapist, psychologist… (audiologist for hearing, optometrist for vision; could
have been covered earlier)

9. Thinking about Michael’s reading, handwriting and how he tries to spell words, what feedback have you received so far
about his progress?

10. June, can you please tell me the details of any literacy interventions that Michael might have done? Good idea to talk
about the informal tutoring/extra reading groups he did after school, that did not make much of a difference

11. Does Michael have any experience with reading or writing using technology to help?

12. How informed do you feel about the way Michael’s school, his teachers, teach reading, spelling and handwriting?
 SPH511 Categorisation of client information following Case History Interview SIM

Georgia Copeland; Master of SP student

13. I am wondering if Michael might be experiencing any changes in his life, or demonstrating any behaviour changes.
What can you tell me, June? Michael is still the ‘same old Michael’ with his friends outside of school, seems happy, but the
teacher tells me….

14. How do you think Michael might be feeling about himself at the moment? I think he has realised everyone else is
“taking off” with their school work and he is a bit stuck… that might be making him feel….

15. What else would you like me to know about Michael’s development? Thank you so much June.
SPH511 Categorisation of client information following Case History Interview SIM

Georgia Copeland; Master of SP student