True North SLP | Intake Form

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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.

Parent/Guardian Name *

Email *

Phone Number *

Child's Name *

Child's Date of Birth *

YYYY

Does your child have a current diagnosis? *

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? *

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? *

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

8:30AM-12PM

12PM - 3PM

3PM - 5PM

5PM - 8PM

Is your child currently attending daycare or school? If so, where? *

Has your child previously received SLP services? *

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

Any other information we should know?

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:

I have an initial consultation booked with:

I was referred to:

No specific SLP at the moment

Jill Northwood

Natalie Douglas

Marla Kerr

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

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