New Client Questionnaire ← BackThank you for your response. ✨ Child’s Name(required) Date of Birth (DD/MM/YYYY)(required) Age (years)(required) Address(required) Person with responsibility(required) Email(required) Phone(required) GP name and address(required) Nursery / School / Pre-school(required) Select all that apply to your child They join words together They have difficulty with particular sounds They cannot understand what I say They have poor listening and attention I cannot always understand what they say Other people cannot understand what they say Please outline any concerns you have about you child’s speech and language On a scale of 0-10 how concerned are you about your child’s speech and language (0= not at all, 10= extremely ) Is your child worried about their speech and / or language? Yes No Any previous input with Speech and Language therapy? Yes No Does your child use a dummy? Yes No Is there a family history of speech, language or communication difficulties? Yes No If yes, please describe Any complications during pregnancy / birth? If so, please describe Has your child had any illnesses or hospital stays? If so, please describe Approximately what age (months) was your child when they reached the following milestones Sitting Crawling Walking First words Putting words together (if age appropriate) Potty trained (if age appropriate) Do you have concerns about the following Behaviour Yes No Sleep Yes No Eating / Drinking / Swallowing Yes No Eyesight Yes No Hearing Yes No Has your child been referred for a hearing test / had a hearing test? Yes No What does your child like to play with? How do they play with other children? Do you have any concerns with their play? Are any other professionals involved with your child, select all that apply Health Visitor Social Worker Educational Psychologist Ear, Nose and Throat Behaviour Support Speech and Language Therapy Physiotherapist Occupational Therapist Audiologist Paediatrician Other (specify) Any other relevant information: 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 Submit formSubmitting form Δ
Bayburn Speech Therapy