Client Background Information


Please complete the Client Background Information form below. Once completed and submitted, our clinic director will review the information within a timely manner. You will be contacted by one of our team members shortly to book your appointment.

Feel free to call us directly to book an appointment at 403-455-4072



  • MaleFemale










  • YesNo


    YesNo


    YesNo

    Speech and Language History




    Does your child understand:

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    Hearing

    YesNo

    YesNo

    Social/Play History

    Prenatal and Birth History

    YesNo

    YesNo

    Education

    YesNo

Disorders and delays impact us in different ways.

Autism Spectrum Disorders | Attention Deficit | Hyperactivity Disorder | Sensory Processing Disorder | Apraxia Developmental Coordination Disorder | Developmental Delay | Learning Disabilities | Delays in Literacy | Speech Delays Written Output Disorder | Feeding Delays | Language Delays | Social Communication Delays

Pathways Pediatrics Clinic: Lakeview Plaza, #108 – 6449 Crowchild Tr. SW, Calgary, AB, T3E 5R7 | Phone: 403-455-4072 | Email: info@pathwayspediatrics.ca

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