Language
English (US)
Spanish (Latin America)
SPEECH MATTERS
Specialize in Speech Therapy for Children and Adults.
New Client Registration
Please answer each question to the best of your knowledge
Client and Family Information
Full Name
*
Name as per official Document
Birth Certificate No / FIN
Starts with T or G
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
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Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
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Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
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Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
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Guadeloupe
Guam
Guatemala
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Guinea
Guinea-Bissau
Guyana
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Indonesia
Iran
Iraq
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Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
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Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
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United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Date of Birth
*
-
Day
-
Month
Year
Date
Gender
*
Male
Female
Name of Parent / Guardian
*
Name as per official Document
Name of Parent / Guardian
*
Name as per official Document
Parent Email Address
*
example@example.com
Parent Email Address
example@example.com - Optional field
Preferred Phone number
*
Phone number
Alternative Phone number
*
Phone number
Primary Language (s) Spoken
*
English
Mandarin / Chinese
Malay (Bahasa Melayu / Indonesia
Tamil / Hindi
Other
Primary Concern
*
Speech / Language
Communication
Feeding /Swallowing difficulties
Voice
Other
If other, please fill in the primary reason for the appointment.
Referred by
*
Self referred
Friend / Family
School / Teacher
Doctor / Therapist / Psychologist
Name of Dr (or Clinic) / Therapist / Psychologist
Medical History
Please complete each question to the best of your knowledge.
What was the mother's length of pregnancy with the patient?
*
37-40 weeks
30-36 weeks
25-29 weeks
25 < weeks
Delivery Information
*
Natural Birth / Vaginal
Induced
Assisted (Forceps / Vacuum)
C-Section
Did any of the following complications apply at time of birth?
*
Jaundice
Prolonged Stay at NICU
Low birth weight
Breathing Difficulties
Sucking/Swallowing difficulties
Infection of baby or mother
Complications at Birth
Heart/Cardiovascular
Low APGAR SCORE
Hypoxia / Low Oxygen Levels
None of these
Other
Has your child experienced any of the following medical complications?
*
Asthma
Cancer
Genetic Disorders
Diabetes
Meningitis
Physical Impairment
Brain Injury
Hearing Loss
Ear Infections
Vision loss
Stroke
Cerebral Palsy
None of these
Does your child have any of the following?
*
Autism Spectrum Disorder
Developmental Delay
Short Attention Span
ADHD/ ADD
Speech Delay
Motor Development Delay
Behavioural Disorder
Sensory Challenges
Feeding Challenges
Learning Disability
None of these
Additional Medical History/Symptoms
Child Development History Information
Fill in this section to the best of your ability. It would provide information on factors which may affect your child's communication or learning development.
Motor Development Milestone- When did your child sit independently?
*
Between 5- 9 months
After 9 months
Still unable to sit independently
Unable to recall
Motor Development Milestone- When did your child start to crawl?
*
Between 6- 9 months
After 9 months
Did not crawl
Unable to recall
Motor Development Milestone- When did your child start walking (first steps)?
*
Before 11 months
Between 11-15 months
After 15 months
Still unable to walk independently
Unable to recall
Interventions your child has received or is receiving
*
Physiotherapy
Occupational Therapy
ABA Therapy
EIPIC / Early Intervention
Educational Therapy / Learning Support
Dyslexia Support (DAS or Similar)
None
Other
If other, please list the concern below.
Speech- Language History
What is your primary concern regarding your child's speech/language?
*
Early Communication Challenges
Articulation / Speech
Language
Fluency / Stuttering
Other
None of these
If other, please list the concern below.
Do you have concerns about your child's hearing
*
Yes - has a hearing loss
Yes - does not seem to respond to name / sounds
No - tested at birth and no issue raised / no concern
Not sure
When did your child say his/her first word?
*
Between 10- 15 months
Between 16 - 18 months
Between 19-24 months
After 24 months
My child is not speaking yet
Approximately how many total words does the child use? (For children aged under 2 years old)
How well can your child understand instructions?
*
Understands only when I point / gesture
Only understands instructions within the home environment
Understands most things children his / her age understand
Not sure
How well can your child express him/herself?
*
Not able to talk yet
Generally 1-2 word output
Speaks in short sentences
Speaks in sentences
I am concerned how he / she produces sentences
Able to express him/herself like most children of the same age
Not sure
How clear is your child's speech?
*
Unclear to family, school or others
Some sounds are still not produced well
No concerns about speech sounds
Not sure
Has your child received speech therapy before this or is your child receiving speech therapy?
*
Yes
No
Please provide information on speech therapy received.
Has your child started preschool / kindergarten / school?
Yes
No
Do teachers have concerns about your child?
Yes
No
Please provide information on the teacher's concerns.
Detail your concerns
Let us know your specific concerns about your child's communication challenges.
This form is submitted by
Name of Parent / Guardian
*
Name as per official Document
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example@example.com
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