ABOUT YOU

Your Name (required)

Your Email Address (required)

Your Contact Telephone Number - Mobile number is best (required)

ABOUT YOUR CHILD

Your Relationship to the Child (required)

Child's First Name (required)

Child's Sex (required)
MaleFemale

Child's Age (required)

MEDICAL HISTORY

Were there any issues with pregnancy? (e.g. Preterm) (required)

Were there are any issues with birth? (e.g. C-section, special care baby unit) (required)

PLease list medical issues since birth (e.g. recurrent ear infections, tonsillitis, asthma) (required)

Any medications? (required)

Do you see any other medical professionals regularly? (e.g. Paediatrician, OT, physiotherapist, health visitor, dentist)? (required)

MILESTONES

Approximately when did your child start walking? e.g. 12 months (required)

Say his/her first words? e.g. 12 months (required)

When was he/she toilet trained? e.g. 3 years (if applicable)

Did he/she have any problems weaning? (required)

How is their diet now? (e.g. textures, tastes, a good variety or a fussy eater) (required)

SPEECH THERAPY HISTORY

Has your child received speech and language therapy in the past? If yes, please give details. (required)

FAMILY HISTORY

Has anyone in the family had speech and language therapy? If so, please give a brief description. (required)

Please describe your child's speech, language and/or communication difficulty. (required)

How do you think he/she feels about it? e.g. aware/unaware (required)

Are there any difficulties with participating at school? With friends? With the family? (required)

What support would you like from speech and language therapy? (required)
Select one or more from the following:
Advice and guidanceAssessmentDetailed reportRegular therapySupport to try therapy myselfSupport for homeSupport for schoolTherapy to supplement current NHS support

I accept that you can use this data as part of ongoing speech and language therapy, assessments and/or reports that we have agreed to.

YOU MUST TICK THE ACCEPTANCE BOX BELOW BEFORE YOU CAN HIT THE SEND BUTTON