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: #130, 7220 Fisher Street SE, Calgary, AB, T2H 2H8 | Phone: 403-455-4072 | Email: info@pathwayspediatrics.ca

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