Screen Reader Mode Icon

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.

Question Title

* 1. Client's Name

Question Title

* 2. Date of Birth

Date

Question Title

* 3. Phone Number

Question Title

* 4. Email Address

Question Title

* 5. Home Address

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

* 11. Your Occupation

Question Title

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

Question Title

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

Question Title

* 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

Question Title

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

Question Title

* 16. Do you have any formal diagnosis?

Question Title

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

Question Title

* 18. Have you seen a Speech Pathologist previously?

Question Title

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

Question Title

* 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.

Question Title

* 21. What are your interests and hobbies?

Question Title

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

0 of 44 answered
 

T