New Client Intake Form - Accessible Speech-Language Pathology PLLC

49 West Avenue South, Hamilton, Ontario, L8N2S2, Canada loren@accessiblespeechlanguagepathology.com

First Name*

Last Name*

Email *

Phone *

How did you hear about us? *

Please answer this question.

What is the name of the parent or legal guardian of the minor who will receive speech therapy services?

First Name: *

Last Name: *

What is the name of the minor who will be receiving speech therapy services? The client is the minor.

First Name: *

Last Name: *

Home Address *

Date of Birth of the Client *

Client's Sex (sometimes this information is needed to compare client's current skills to the population assessment tools were normed on)

Client's Pronouns *

Speech Therapy Questions

What do you hope to accomplish or gain from working with a speech-language pathologist? Please be as detailed as possible when answering this question. *

What is your general availability for speech therapy sessions? *

We offer speech therapy services via telepractice (virtual). Do you agree to receive speech therapy services via telepractice? *

Please answer this question.

Has your child been evaluated by another speech-language pathologist in the past year? If so, please email a copy of the assessment report and speech therapy goals. *

NoYesNo

Has your child participated in speech therapy services in the past? *

NoYesNo

What are your child's interests/hobbies/passions/favorite things? *

What are your child's strengths?

What languages are spoken in your home? *

How does your child currently communicate? *

Does your child have any diagnoses relating to speech, language, feeding and/or communication? *

NoYesNo

What does your child know about their diagnosis or diagnoses?

What is your child's neurotype?

What does your child know about their neurotype? If they are Autistic, have they been told in a neurodiversity affirming manner?

Should the speech-language pathologist be aware of any cultural or religious beliefs/values/customs before beginning to work with your family?

NoYesNo

Is there anything else the speech-language pathologist should be aware of before beginning to work with your family (ie things that may trigger a trauma response, things the client is afraid of or anxious about)?

NoYesNo

Do you consent to your child receiving speech therapy services from Accessible Speech Language Pathology? *

Emergency Contact

Emergency contact name *

Relationship *

Phone *

Allergies

Include allergies to medications, environment, food, and animals.

List allergen, severity, and type of reaction

I certify the information above is complete and accurate. I acknowledge that the information on this form will be kept securely stored and encrypted on Colib website, viewable by the organization I plan to visit.

Your information is kept by the clinic for as long as its professional order requires, and your account data for as long as your account is active. A deleted record is permanently purged 45 days after its deletion. Details in our privacy policy.

Signature :

New Client Intake Form - Accessible Speech-Language Pathology PLLC

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The information has been received.

Did you enjoy the Colib experience?

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Speech Therapy Questions

Emergency Contact

Allergies

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