Client Information Form

Please complete this short form prior to your first speech and language therapy appointment. It helps to plan the assessment and saves time on the day. Alternatively, you can print it out and bring it with you.

You can also use it to make a general enquiry about speech and language therapy.

Please also be assured that this form is secured by SSL encryption (HTTPS) which means that all data that you enter is protected and will be transferred to our server securely. No information is shared with any third party. All customer data is stored on a password secured database in accordance with the Data Protection Act 2003.

All fields are required to be completed.

ABOUT YOU

ABOUT YOUR CHILD


MEDICAL HISTORY

MILESTONES

SPEECH THERAPY HISTORY

FAMILY HISTORY


Advice and guidanceAssessmentDetailed reportRegular therapySupport to try therapy myselfSupport for homeSupport for schoolTherapy to supplement current NHS support