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ABOUT
Our Clinic
Meet the Team
What is Speech Pathology?
SERVICES
GROUPS & CAMPS
EVENTS
BOOK AN APPOINTMENT
ABOUT
Our Clinic
Meet the Team
What is Speech Pathology?
SERVICES
GROUPS & CAMPS
EVENTS
BOOK AN APPOINTMENT
ABOUT
Our Clinic
Meet the Team
What is Speech Pathology?
SERVICES
GROUPS & CAMPS
EVENTS
BOOK AN APPOINTMENT
Chatterbox Speech Camp/Workshop Registration Form
Kelly Higgins
2018-06-15T13:44:27+00:00
Chatterbox Speech Camp/Workshop Registration Form
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Step
1
of 2
General Information -
Name:
First
Last
Date of Birth:
Address:
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
Phone
Phone (ALT)
Email:
Background -
Provide information and history about any of the following:
Mother's Name:
Occupation:
Father's Name:
Occupation:
Does the client live with both parents?
Yes
No
Other people in the home:
Was hearing tested?
Yes
No
Primary language spoken at home:
Other language(s) spoken at home:
If Child does not live with both parents, please provide any documents for custody concerns. Consent needs to be provided by the adult bringing the child to the assessment/consult to share any information with others. Please provide more information to the SLP at the appointment, if needed.
Medical History -
Provide information and history about any areas of concern. Any allergies?
Any surgeries, major accidents or hospitalizations?
Diagnosis or learning difficulties?
Who provided the diagnosis and when was the diagnosis? If any report is available please provide.
Next
Speech Concerns -
Describe the concerns you have for the child?
Any family history of speech and language concerns or learning disabilities or reading concerns?
Is the child aware of the concern? If yes, how does he/she feel about it?
Educational History -
Provide information on any of the following:
Name of school:
Grade:
Concerns academically:
Behavior:
Teacher:
Special considerations/support:
How does the child interact with others at school?
Is there a recent IEP? Please attach or provide the goals, weaknesses and strengths:
2019/2020 Programs -
Please select one or more programs:
Littles Literacy - (Tues 5pm) Feb 4th - Mar 10th, 2020
Littles Literacy - (Tues 5pm) Mar 24th – April 28th, 2020
Littles Literacy - (Tues 5pm) May 5th – June 9th, 2020
Littles Literacy (Sat 10am) February 8th – March 14th, 2020
Littles Literacy (Sat 10am) March 28th – May 2nd, 2020
Littles Literacy (Sat 10am) May 9th – June 13th, 2020
Literacy Skills - (Tues 6pm) Feb 4th - Mar 10th, 2020
Literacy Skills - (Tues 6pm) March 24th – April 28th, 2020
Literacy Skills - (Tues 6pm) May 5th – June 9th, 2020
Social Skills - (Tues 7pm) February 4th – March 10th, 2020
Social Skills - (Tues 7pm) March 24th – April 28th, 2020
Social Skills - (Tues 7pm) May 5th – June 9th, 2020
Superheros Unite - (Mon 6pm) February 3rd – March 9th, 2020
Superheros Unite - (Mon 6pm) March 23rd – April 27th, 2020
Superheros Unite - (Mon 6pm) May 4th – June 8th, 2020
Consent -
Please note that by providing this information you are giving consent for your child listed above to complete the Chatterbox Speech Camp or other Chatterbox workshops, enrolled in. Consent is being provided to allow the child above to participate in all the camp activities which may include but are not limited to, walks, hikes, daily crafts, painting, special activities such as therapy dog visits, animal/ zoo tech presentations, science experiments, getting dirty, and most of all having FUN! If you have any concerns please alert Chatterbox camp staff or email info@simcoespeechclinic.ca. We reserve the right to cancel workshops/camp, due to low numbers, full refund will be given if this occurs.
Person completing the form:
Relationship to child:
Signed:
Please sign here
Date / Time
Date
Time
Message
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