Listen Home Speech Sounds Clinic... Speech Sounds Clinic Application Form Please fill in the form below to apply for our Speech Sounds Clinic services. It must be completed prior to the assessment session. 1Details2History3Parent observations/comments4Additional information DetailsDate:(Required) MM slash DD slash YYYY Child's detailsChild's full name:(Required) First Last DOB:(Required) MM slash DD slash YYYY Parents detailsParent name:(Required) First Last Address:(Required) Street Address City Postcode Phone number:(Required)Parent Email:(Required) School contact detailsSchool/preschool:(Required)Teacher:(Required)Days attending/grade:(Required)Contact person:(Required)Contact Phone:(Required)Contact Email:(Required)Summary of presenting problem/concernsPlease state problem/concerns:Age noticed:Who noticed:Family HistoryFamily historyPeople living with child:Relationship:DOB (siblings) Full Name: First Last DOB: MM slash DD slash YYYY Family history of speech/language/learning difficulties:Cultural and linguistic backgroundCultural background:Language(s) spoken at home:Language(s) spoken by your child:Language(s) understood by your child:Language your child prefers to speak at home:What would you like us to know regarding your culture, values or beliefs?How would you like us to take this into consideration when treating your child? This field is hidden when viewing the formHistoryHistoryDevelopmental historyLength of pregnancy:Complications during pregnancy:Birth weight:Birth complications:Speech developmentQuite or noisy baby? Quiet baby Noisy baby Babbled:Please state the ageTwo word combinations:Please state the ageFirst words:Please state the ageSentences:Please state the ageMotor developmentSat alone:Please state the ageCrawled:Please state the ageWalked:Please state the ageToilet trained:Please state the ageMedical historyAny diagnosis or conditions we should know about?Significant health problems in the past:(eg. Ear infections, asthma, seizures, hospitalisations)Current health concerns:Hearing tested: Yes No Vision tested: Yes No Requirements: Hearing Aid Glasses Not applicable Parental observation/commentsReceptive language:(eg. Understanding what is said to them, following instructions)Expressive language:(eg. Ability to express ideas using appropriate vocabulary, sentences and grammar)Articulation:(eg. Production of speech sounds)Fluency:(eg. Stuttering or dysfluency)Voice:(eg. Quality, pitch, volume)Social skills:(eg. Turn taking in conversation, sharing, eye contact)Learning:(eg. General learning, reading, spelling, writing)Behaviour and attention: Additional informationList places your child spends most of their time:(eg. Day care, grandparent’s house, park)Activities your child is involved in:Toys/games your child enjoys:Has your child previously seen any therapists or specialists? Yes No Contact Details of Therapist or SpecialistName: First Last Phone:Email: FileMax. file size: 30 MB.Are there any significant or recent family events or circumstances that may have had an impact on the customer?(chronic health issues, transitions, loss of loved one, change in financial status)YesNoWhat are your expectations of what you would like your child to achieve from the sessions?NameThis field is for validation purposes and should be left unchanged.