Calgary New Client Registration Form

New Client Booking

Thank you for choosing Pathways. We are committed to helping your child meet their goals, and we want to do everything we can to make this a positive and fun learning experience for your whole family. In most cases your child’s assessment will be for 1 hour, but we cannot anticipate what their needs may or may not be until we have our first appointment with you. We may need more time to complete our assessment and/or report writing if requested, or if necessary. After your appointment, you and our therapist will discuss what your child’s needs are and together you can decide what the most appropriate course of action will be going forward.

Once completed and submitted, our clinic director will review the information within a timely manner. You will then be contacted by one of our team members there after to book your appointment.

Where are you located? *

Calgary
Kelowna/Lake Country BC

Name of person completing form *

First

Last

Relationship to child

Referred by eg. parent/school/doctor *

Child's name *

Gender *

Male
Female

Date of birth *

Primary address *

Parent/guardian name(s) *

Primary phone *

Alternate phone

Email *

Please list other children in family (including age)

Reason for completing this form *

Speech services
OT services
Other

If other, please describe

Does your child have any diagnosis or disorders? *

If yes, please describe

Has the child been seen by a Speech-Language Pathologist? (copy) *

If yes, date

Name of SLP and facility

If yes, findings

Has the child been seen by an Occupational Therapist? *

If yes, date

Name of OT and facility

If yes, findings

Has the child been seen by other professionals? *

If yes, please describe

Speech and Language History

What is your child's first Language? *

Second language?

When did your child say his/her first words? *

When did your child combine words to form sentences? *

How does your child typically communicate (eg. with gestures or words)? *

Give an example of something your child communicated today (either with words or gestures) *

If with words, how many words does your child typically put together to form a sentence?

Does your child understand:

a) Single directions (e.g. point to your nose) *

b) 2 step directions (e.g. get your shoes and give them to me) *

c) Simple questions (e.g. where’s your teddy?) *

How well do you understand your child (from 0% to 100%)?

Selected Value: 0

How well do other family members understand your child (from 0% to 100%)?

Selected Value: 0

How well do strangers understand your child (from 0% to 100%)?

Selected Value: 0

Are there certain sounds that your child has difficulty pronouncing? *

If yes, provide examples

What does your child do if she/he is not understood? *

Does your child stutter? (e.g. gets stuck, repeats sounds/words) *

If yes, describe

Hearing

Has your child had ear infections? *

If yes, how many?

Does the child seem to have any difficulty hearing? *

Has your child had a hearing test? *

If yes, what were the results and recommendations?

Social/Play History

Does your child enjoy or avoid the company of other children? *

What are your child’s favourite interests? *

Does your child make eye contact with you when speaking or interacting? *

Motor and Sensory History

At what age did your child sit independently? *

At what age did your child crawl? *

At what age did your child walk? *

At what age did your child finger feed? *

At what age did your child toilet train? *

Is your child able to undress or dress themselves? *

Does your child enjoy participating in crafts, drawing, playing with manipulative toys? *

Does your child print? *

Does your child enjoy playing on playground equipment? *

Does your child display any reactions to sensory input that does not seem typical of children their own age (ex: reactions to loud noise, avoid wet/sticky textures, avoid going upside down, eats limited food textures/tastes) *

If yes, describe

Is your child able to feed themselves? (finger feed, hold a spoon, drink through a cup or straw)

Does your child drool? *

Do you have any concerns about your child’s eating? *

If yes, describe (copy)

Do you have any concerns about your child’s sleeping? *

If yes, describe

Prenatal and Birth History

Please describe any complications during pregnancy or birth

Please indicate any illnesses which the child has had, such as high fevers, measles, tonsillitis, earaches, etc. *

Does your child have any allergies? *

If yes, please describe

Education

Does your child currently attend pre-school, school or daycare? *

If yes, list school and grade

Has your child's teacher reported any concerns? *

If yes, please describe

Does your child receive any therapy services at school? *

Please use this space to comment on any other information you feel is important