FORM NAME

DESCRIPTION

BIOGRAPHICAL INFORMATION

First name of child

Last name of child *

Date of Birth (DD/MM/YYYY) *

Parent Name *

Cell Phone *

Email of parent *

Other Parent/Guardian Name *

Cell phone of other Parent/Guardian *

email of other Parent/Guardian *

What is your Address *

What is your Address

City

State/Province

Zip/Postal

Country

Do you have any funding?

OAP

No grants

TREATMENT GOALS

Of your above concerns, what is your TOP # 1 priority for the next 12 weeks?

What type of therapy are you interested in (check all that apply)

Speech Therapy (1 on 1)

BCBA 1 on 1

Instructor Therapist (1 on 1)

GABA Groups

BIRTH AND MEDICAL HISTORY

Was your child born full term? If not, please state gestational age.

Were there any complications during pregnancy or birth? If yes, please explain.

What was the method of delivery (e.g., vaginal, breech, cesarean)?

Is your child currently taking any medications? If yes, please list medication(s).

Has your child had any surgeries, accidents and/or significant illnesses? If yes, please explain.

Does your child have any known food allergies? If yes, are these allergies anaphylactic, and does your child carry an epipen with him/her? Please explain.

When was your child's most recent hearing and vision tests? Please provide date and results.

Has your child had any ear infections? If so, how many and what was the date of the last ear infection?

If yes, what year were you diagnosed?

What is your family physician's name and phone number?

SOCIAL HISTORY

Who does your child live with? Please indicate any siblings, and siblings' ages.

Who does your child spend most of their time with? Please explain?

What languages are spoken in the home? What languages does your child speak? *

Does your child attend daycare, preschool, elementary school, etc.? If yes, please state program/school, and grade, if applicable.

Does your child receive any special services within the school?

SPEECH AND LANGUAGE

Please describe your main concerns regarding your child's speech and language.

What is your child's primary mode of communication (gestures, signing, single words, phrases, full sentences, augmentative device etc)?

Are there any speech-language or hearing problems in your family? If so, please describe.

Has your child received speech-language services in the past? If yes, please indicate the name of clinician, the date and time span of therapy received.

How much of your child's speech do you understand?

0-25%

25-50%

50-75%

75-100%

How much of child's speech does a stranger or unfamiliar listener understand?

0-25%

25-50%

50-75%

75-100%

Please indicate the approximate age your child began to: 1. Babble; 2. Say first words; 3. Combine 2-3 words together; 4. Speak in full sentences;

Does your child have more challenging behaviours than same aged peers?

Yes

no

If yes, please describe the behaviours you have observed.

Paragraph

How did you hear about us?

Google

Professional referral

friend

OSLA