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True North SLP | Intake Form
By completing this Intake Form, it will allow us to have a better understanding of your child and the support we can provide to help them grow on their communication journey.
Thank you for taking the time to fill out this form.
** Please note: We are not accepting new FSCD clients at this time **
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* Indicates required question
Parent/Guardian Name
*
Your answer
Email
*
Your answer
Phone Number
*
Your answer
Child's Name
*
Your answer
Child's Date of Birth
*
MM
/
DD
/
YYYY
Does your child have a current diagnosis?
*
Your answer
Area(s) of concern for your child's development?
*
Speech Sounds - Example: /k/ as in "car" or the /s/ sound is slushy sounding
Understanding Language - Following directions, answering questions, understanding words and concepts
Using Language - Increasing their vocabulary, making longer sentences, using appropriate grammar, telling stories
Social Communication - Understanding how to engage and maintain a conversation with a peer, turn taking, sharing, managing feelings
Fluency - Child is stuttering when talking
Myofunctional Therapy - Developing the appropriate tongue placement at rest and when swallowing
Other:
Required
Has your child's hearing been screened recently?
*
Yes - Hearing was within normal limits
Yes - Hearing concerns have been identified
No - Hearing seems fine
No - We have concerns
Other:
What language(s) are spoken in the home?
*
Your answer
Where do you want therapy sessions to take place?
*
In our home
In the community (e.g., public library)
In my child's daycare/school
Required
What community do you live in?
*
Your answer
How often are you interested in having therapy sessions?
*
Once per week
Twice per month
Other:
When would you prefer therapy sessions?
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
8:30AM-12PM
12PM - 3PM
3PM - 5PM
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
8:30AM-12PM
12PM - 3PM
3PM - 5PM
Is your child currently attending daycare or school? If so, where?
*
Your answer
Has your child previously received SLP services?
*
Your answer
Do you have a Family Support for Children with Disabilities (FSCD) contract? *
Yes - Behavioural / Developmental Support (6 month contract)
Yes - Specialized Services (1 year contract)
Awaiting approval for a contract
No
Clear selection
Any other information we should know?
Your answer
How did you learn about True North?
*
Friend/Family Member
Referral from another professional
Internet Search
Children's Link
ASAPP - Alberta Speech-Language Association of Private Practitioners
Instagram
Facebook
Lumino Health
Other:
At this time, if True North SLP is unable to offer services do we have your permission to share this form with our SLP colleagues that may potentially have availability?
*
Yes
No
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