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Staff
Menu
Leor.pd
Careers
Open Positions
Families
Fee Payments
Forms
Family Enrolment Form
Incident Report
Family Feedback Form
Family Departure Survey
Parent or Guardian Consent Form
Transport Request Form
Useful Documents
Staff
Speech Ouestionnaire
Speech Questionnaire
Step
1
of
4
25%
Please complete this questionnaire prior to your first appointment.
Your Name
*
First
Last
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Phone
*
Email
*
Name of Child
*
First
Last
Date of Birth
*
DD slash MM slash YYYY
Who lives with the child at home?
*
Who is available to do 10 mins practice with child each day? (if recommended)
*
Consents
Consent forms completed:
*
Privacy
Photo and video
Telehealth
If receiving NDIS, do you give consent for allied health to receive a copy of your plan?
*
Yes
No
I don't receive NDIS
Reason for Referral
Who referred your child?
*
GP
Nurse
Allied Health
Educator
Parent
Other
Other
*
Why was the child referred?
*
What are your main concerns?
*
Telehealth
Will your child be able to attend an initial 30 minutes telehealth session via zoom?
*
Yes
No
A laptop, a tablet or phone with a reliable internet connection and a quiet room will be required.
Who will be available to facilitate this session between your child and therapist?
*
Parent
Educator
Other
Other
*
Background
Were there any complications during pregnancy or birth?
*
Yes
No
How many weeks was your child born at?
*
weeks
Did you experience any feeding difficulties when your child was born?
*
Yes
No
Was your child breast or bottle fed?
*
Breast fed
Bottle fed
At what age did your child transition to solids? How was their transition to solids? Were there any difficulties?
*
Are there any current difficulties with eating, drinking or swallowing?
*
No
Yes, with eating
Yes, with drinking
Yes, with swallowing
Does your child have any oral habits?
*
Thumb/finger sucking
Chewing clothes/hair
Sucking blanket/toys
Other
Other
*
Has your child had any ear infections?
*
Yes
No
When and for how long?
*
Has your child experienced reflux?
*
Yes
No
When and for how long? Please describe any treatment that was given.
*
Does your child have any allergies?
*
Yes
No
Does your child ever snore?
*
Yes
No
Is your child currently taking any medication?
*
Yes
No
Does your child have any medical diagnosis?
*
Yes
No
Has your child had a hearing test?
*
Yes
No
When?
Are you able to supply the results?
*
Yes
No
Is your child currently under the care of any medical, educational or allied health professionals?
*
Pediatrician
Ear, nose and throat specialist (ENT)
Psychologist
Occupational Therapist
Speech Pathologist
Physiotherapist
Orthodontist
Learning Support Teacher
Other
None of the above
Other
*
Do you give permission for Leor allied health staff to collaborate with the above professionals and to exchange information relevant to your child's care and development?
Yes
No
Pediatrician Contact Details
Name
First
Last
Practice
Phone
Email
Ear, nose and throat specialist (ENT) Contact Details
Name
First
Last
Practice
Phone
Email
Psychologist Contact Details
Name
First
Last
Practice
Phone
Email
Occupational Therapist Contact Details
Name
First
Last
Practice
Phone
Email
Speech Pathologist Contact Details
Name
First
Last
Practice
Phone
Email
Physiotherapist Contact Details
Name
First
Last
Practice
Phone
Email
Orthodontist Contact Details
Name
First
Last
Practice
Phone
Email
Learning Support Teacher Contact Details
Name
First
Last
Practice
Phone
Email
Please give contact details for the professional your child is under the care of
Name
First
Last
Practice
Phone
Email
Development
Did or does your child have any difficulties with the following?
Sitting up
Crawling
Pincer grip
Drawing
None of the above
At what age did your child begin walking?
*
Language Milestones
At what age did your child begin to babble?
*
At what age did your child say their first words (12 months)?
*
At what age did your child begin to say 2 word phrases (2 years)?
*
At what age did you child begin talking in full sentences?
*
Expressive Language
Do you have any concerns with your child’s vocabulary? e.g. does your child overuse non-specific words such as “I want this.”
*
Do you have concerns about your child’s ability to use appropriate sentence structure?
*
Do you have concerns about your child’s ability to use grammar (e.g. appropriate use of past tense / plural etc)?
*
Receptive Language
Is your child able to follow instructions (e.g. “Get your hat” or “sit at the table”)
*
Do they understand wh- questions? (eg. who, what, where)
*
Speech
Does your child have trouble making any of the speech sounds?
*
Yes
No
What sounds have you noticed? Please give examples if possible.
*
Did/Does anyone else in the family have difficulties with speech sounds?
*
Yes
No
If so, can you please give examples?
*
Fluency (Stuttering)
In everyday speech does your child often have:
*
Repetitions in their speech
Pauses
Overuse of filler words (e.g. “um”, “ahh” etc)
None of the above
Does anyone else in the family have difficulties with stuttering?
*
Education and social development
Did/ does your child currently attend play group outside the family home?
*
Yes
No
Does your child attend any regular social outings (e.g play dates, extra curricular activities, sports, mothers group)?
*
Yes
No
Who does your child socialise with on a regular basis?
*
Immediate family/siblings
Grandparents
Cousins
Aunties
Uncles
Family friends
Friends from play group
Friends from mothers group
Friends from preschool
Friends from school
How many siblings and what are their ages?
*
Play
How would you describe your childs play skills? (tick all/any that apply)
Enjoys playing alone
Enjoys playing alongside other children (e.g. will sit next to others and play with similar toys but is not interacting with play partner)
Enjoys joint play and interacting with other children
Enjoys play with parent/care
Requires the parent/carer/play partner to initiate play
Participates in turn taking activities easily
Engages in pretend and imaginative play
Do you have any comments regarding your childs play skills?
Goals
What are your main goals for your child's communication?
*
If you would like to upload any reports, recordings or other documents relevant to the assessment, please attach them here.
Max. file size: 128 MB.
Phone:
02 9051 0511
Email:
learn@leor.com.au
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