New Client Form Speech Therapy - New Client Form Step 1 of 2 50% Child's Name* First Last Gender*FemaleMaleChild's Date of Birth* Month Day Year Child's Phone Number (if applicable)Home Mailing Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Name of School (include schedule if pre-school):Parent #1 Name* First Last Parent #1 Phone Number*Parent #1 Email* Parent #2 Name First Last Parent #2 Phone NumberParent #2 Email Languages spoken at home (include all languages and specify the primary language):*Has your child had a hearing test / screen?* Yes No Provide dates and results:Has your child suffered from repeat ear infections?* Yes No Please include any family history of speech, language or hearing problems:Does your child have siblings? Yes No Name of sibling:Age of sibling:Name of sibling:Age of sibling:Name of sibling:Age of sibling:Name of sibling:Age of sibling: Names of important people (teachers / friends / neighbors):Your child's interests and favourite things:Things that upset your child:Describe your concerns related to your child's speech-language skills:Do strangers have difficulty understanding your child's speech?Please give some examples of what your child says:Describe any other concerns you have regarding your child’s development (social skills, behavior, play, movement, sleep, eating / dietary, late milestones…):Please list any other Professionals or Agencies working with your child:Please list any significant illnesses, conditions, accidents, surgeries or hospitalizations:What is your desired outcome?Form completed by: First Name Last Name Date MM slash DD slash YYYY
