New Client Questionnaire Go backYour message has been sent Child’s Name(required) Warning Date of Birth (DD/MM/YYYY)(required) Warning Age (years)(required) Warning Address(required) Warning Person with responsibility(required) Warning Email(required) Warning Phone(required) Warning GP name and address(required) Warning Nursery / School / Pre-school(required) Warning Select all that apply to your child They join words together Warning They have difficulty with particular sounds Warning They cannot understand what I say Warning They have poor listening and attention Warning I cannot always understand what they say Warning Other people cannot understand what they say Warning Please outline any concerns you have about you child’s speech and language Warning On a scale of 0-10 how concerned are you about your child’s speech and language (0= not at all, 10= extremely ) Warning Is your child worried about their speech and / or language? Yes No Warning Any previous input with Speech and Language therapy? Yes No Warning Does your child use a dummy? Yes No Warning Is there a family history of speech, language or communication difficulties? Yes No Warning If yes, please describe Warning Any complications during pregnancy / birth? If so, please describe Warning Has your child had any illnesses or hospital stays? If so, please describe Warning Approximately what age (months) was your child when they reached the following milestones Sitting Warning Crawling Warning Walking Warning First words Warning Putting words together (if age appropriate) Warning Potty trained (if age appropriate) Warning Do you have concerns about the following Behaviour Yes No Warning Sleep Yes No Warning Eating / Drinking / Swallowing Yes No Warning Eyesight Yes No Warning Hearing Yes No Warning Has your child been referred for a hearing test / had a hearing test? Yes No Warning What does your child like to play with? How do they play with other children? Do you have any concerns with their play? Warning Are any other professionals involved with your child, select all that apply Health Visitor Warning Social Worker Warning Educational Psychologist Warning Ear, Nose and Throat Warning Behaviour Support Warning Speech and Language Therapy Warning Physiotherapist Warning Occupational Therapist Warning Audiologist Warning Paediatrician Warning Other (specify) Warning Warning Any other relevant information: Warning By submitting this form I confirm that: I have read, understood and agree to the Bayburn Speech Therapy Terms and Conditions that have been provided to me. I consent to treatment for my child and understand that I can withdraw my child at any time. I consent to the therapist liaising with other professionals when necessary. I consent to the use, if required, of audio and/or video recordings as part of my child’s treatment which will be stored appropriately and confidentially. I understand that personal information will be stored as outlined in the data protection policy (available on request). I acknowledge and agree to the terms regarding missed appointments/ late cancellations and that fees may still apply Warning. Submit formSubmitting form Δ
Bayburn Speech Therapy