BOOKING A SPEECH & LANGUAGE CONSULTATION

What is a Consultation for?
It is a discussion of concerns and an information gathering session. Our goal is to compile an informal communication profile capturing your child’s speech and language abilities. We will discuss any next steps/ recommendations that your family should pursue; a wayfinding discussion about all the treatment options that may be available to your child.

Client Name

First Name

Last Name

Client's Age

Parent/Guardian's First & Last Name (put NA if not applicable)

Phone

(###)

###

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What is your main concern?

Have speech & language or occupational therapy services previously been received?

What languages are spoken at home?

Is there any medical history relevant to speech & language abilities or occupational therapy skills (e.g., lots of ear infections, tongue tie, premature birth, surgeries)?

Preferred days of the week and times of day for services (e.g., daytime, weekend, after school, after 5 pm etc.)

Anything else we need to know?