Initial Questionnaire ΔSubmitter's Name Email Phone/Mobile Are you looking for speech therapy for a CHILD or ADULT? Child AdultWhat is your relationship to the child? - Select -ParentGuardianGrandparentOtherPlease describe your relationship to the child needing speech therapy services First Name of Child Last Name of Child Date of Birth of Child Are they male or female? Male Female OtherPlease Specify Are there any special custody arrangements for the child? (eg. separate/divorced parents or guardianship) What is your main concern(s) for your child? (select ALL that apply) Late Talker (early language) Pronunciation / speech clarity (articulation) Expressing thoughts and needs: (expressive language: vocabulary, grammar, story telling, making requests, etc) Understanding what you say (receptive language: answering questions, following directions, etc) Stuttering / Stammering (fluency) Literacy/Reading/Dyslexia Social Skills / Interacting with Peers (pragmatics) Attention and Focus / ADHD and ADD (executive functioning) Voice (raspy voice, hoarsness, nasal voice, etc.) OtherPlease elaborate on your OTHER concerns. What percentage of your child's spoken words do YOU understand? N/A - my child is not yet using words 0% 25% 50% 75% 95-100%What percentage of your child's spoken words would a LESS FAMILIAR adult understand (e.g. a friend or family member who only sees your child occasionally)? N/A - my child is not yet using words 0% 25% 50% 75% 95-100%Feel free to elaborate on your selected concerns (optional) Any relevant or suspected diagnoses (Developmental Delay, ASD, Apraxia, Dyslexia, Ear infections, Hearing impairment, etc)? Do you have any concerns about their hearing? Yes No UnknownPlease elaborate What is your relationship to the adult needing speech therapy services? - Select -Myself: I require the servicesSpouse: I am the spouseParent: I am the parentCaregiver: I am the caregiverOtherPlease describe your relationship to the adult needing speech therapy services. What is THEIR First Name? What is THEIR Last Name? What is THEIR Date of Birth? Are they male or female? Male Female OtherPlease Specify Are there any legal decision-making arrangements in place for the client? (e.g., enacted personal directive, power of attorney, substitute decision maker) What is your main concern(s)? (select ALL that apply) Stroke (aphasia, apraxia, dysarthria) Accent Modification General Communication Coaching (eg. public speaking, work communication, confidence) Swallowing, choking, gagging, (dysphagia) Pronunciation / Speech clarity (articulation) Stuttering / Stammering (fluency) Literacy/Reading or dyslexia Expressing thoughts and needs: (expressive language: vocabulary, grammar, story telling, making requests, etc) Understanding what is said (receptive language: answering questions, following directions, etc.) Social Skills / Interacting with Peers (pragmatics) Attention and Focus / ADHD and ADD (executive functioning) Gender Diverse voice services (feminization, masculinization and/or neutral) Voice(raspy voice, hoarseness, nasal voice etc.) Voice coaching (for singing,public speaking, etc. OtherPlease elaborate on your OTHER concerns Feel free to elaborate on your selected concerns (optional) Are there any relevant or suspected diagnoses ( aphasia, ASD, dyslexia, dementia, ALS, parkinsons, cerebral palsy, hearing impairment, etc)? Any difficulties or concerns with hearing? Yes No UnknownHearing Concern How are they most commonly communicating with you? (select ALL that apply) Full sentences 2 to 3 word combinations Single words / sounds Not speaking Points and gestures AAC device (eg. iPad or communication board)Feel free to tell us more about how they communicate with you (optional) Have you had a Speech Therapy evaluation or services in the past? Yes NoPlease briefly describe your experience with previous services (diagnosis, goals, duration of therapy, etc). (optional) What languages are spoken in the home? English French OtherSpecify Other Languages What are your child's interests and hobbies? Examples: dinosaurs, hockey, paw patrol, video games, geography, trivia, sports, blocks/legos, art/crafts What are their interests and hobbies? Examples: sports/activities, art/creative, gardening, cooking, cards/board games, video games, profession What benefit is the MOST important to you? (pick one) Convenience of Online Therapy Price/affordability Other The Therapist's experience Evening and weekend availability Personalized therapy plans Learning myself how to help themPlease Specify the other Benefit that is MOST important to you What benefit is the LEAST important to you? (pick one) Price/affordability Learning myself how to help them The Therapist's experience Convenience of Online Therapy Personalized therapy plans Evening and weekend availability OtherPlease Specify the other Benefit that is LEAST important to you What days would you be available for the weekly Zoom therapy session? Monday Tuesday Wednesday Thursday Friday Saturday SundayMonday Before School / Work During the day After School / WorkTuesday Before School / Work During the day After School / WorkWednesday Before School / Work During the day After School / WorkThursday Before School / Work During the day After School / WorkFriday Before School / Work During the day After School / WorkSaturday Morning Afternoon EveningSunday Morning Afternoon EveningDo you have Google Drive (or Gmail)? Yes NoNot to worry. We can help with that later.What is your Google Drive/Gmail Email? How did you hear about us? - Select -InstagramOtherGoogleFacebookASAPP websiteOSLA websiteDoctor referralFriends/Family (Word of Mouth)Please input how did you hear about us Submit
