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1. General Information

We ask that you take 10-15 minutes to complete this form with as much detail as possible. This will help the Speech Pathologist when the time comes to start therapy.

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* 1. Client's Name

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* 2. Date of Birth

Date

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* 3. Phone Number

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* 4. Email Address

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* 5. Home Address

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* 6. Parent/ Guardian or Primary Carer (only if applicable)

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* 7. Person completing this form (only if different from above)

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* 8. Please list all family members that live at home? If you have children, please include names and ages

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* 9. What is the Primary Language Spoken at home? Any other Languages spoken at home? 

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* 10. What are your support networks outside of the home- Does anyone else provide care for you?

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* 11. Your Occupation

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* 12. Your Current Workplace, School or Facility that you spend time

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* 13. What areas do you need assistance with? Tick all that may be applicable

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* 14. When did you first notice any of the above concerns? Has the difficulty changed since it was first noticed? Please provide as much information as possible

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* 15. What do you think may have caused the difficulty? Please provide as much information as possible

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* 16. Do you have any formal diagnosis?

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* 17. How do you feel the difficulty has affected your life? Eg. Social Life, Career, Education

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* 18. Have you seen a Speech Pathologist previously?

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* 19. Have any other specialists assessed or treated you? (please select all applicable)

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* 20. Please detail any specialists that have previously treated you or that you are currently engaged with- including type of specialist, name and contact details, when you were seen and the conclusions and suggestions.

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* 21. What are your interests and hobbies?

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* 22. Do you wear glasses or hearing aid? If yes, please state when your most recent eye test or hearing test was

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