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New Client Form
Step
1
of
2
50%
Child's Name
*
First
Last
Gender
*
Female
Male
Child'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):
Parents' Name
*
First
Last
Parents' Phone Number
*
Parents' Email
*
Parents' Name
First
Last
Parents' Phone Number
Parents' 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