Child’s Name
*
First Name
Last Name
Gender
*
Please select
Male
Female
Date of Birth
*
MM
DD
YYYY
Your Email Address
*
Your Address
*
Does the child live at home with both parents?
*
Please select
Yes
No
Mother’s Name
First Name
Last Name
Mother’s Occupation
Mother’s Contact Number
Father’s Name
First Name
Last Name
Father’s Occupation
Father’s Contact Number
Siblings
Please list any siblings, with gender and DOB for each.
Is there a language other than English spoken in the home?
Please select
Yes
No
If yes, what language?
Please list names, with profession and contact number.
I have concerns about my child’s:
Please describe your concerns in more detail:
When was the problem first noticed, and by whom?
Approximate age when your child said single words:
Approximate age when your child said two-word phrases:
Approximate age when your child used simple sentences:
Please indicate any family history of the following:
If you indicated family history above, please clarify who and when:
Previous Speech Pathologist (if applicable):
Were there any concerns during pregnancy/birth?
If yes, please explain.
Has your child experienced any of the following?
If yes to any of the above, please explain.
Has your child experienced any ear infections?
If yes, please explain.
Has your child’s hearing been tested recently?
If yes, when was the test and what were the results?
Do you have concerns about your child’s physical development?
Please select
Yes
No
Please list any current diagnoses:
Approximately when did your child reach the following milestones - sitting? walking? crawling?
Please indicate which of the below your child can do independently:
Please tick the points that are true for your child:
Does your child attend any of the below?
If yes to the above, please confirm details and any concerns of daycare/school:
Name of person completing this form
*
First Name
Last Name
Relationship to Child
*
Cancellation Policy
*
