Toddler Speech & Sensory Group
Fill out the form carefully for registration. Group will take place on Fridays from 9:00-9:45 AM on July 7th, 14th, 28th and August 4th, 11th, 18th.
Caregiver's Name
*
First Name
Last Name
Child's Name
*
First Name
Last Name
Child's Date of Birth
*
-
Month
-
Day
Year
Date
Gender
Please Select
Female
Male
N/A
Email
*
example@example.com
Mobile Number
*
Please enter a valid phone number.
My child can:
Always
Sometimes
Never
Find named objects
Follow one step directions
Follow two step directions
Copy actions
Copy sounds
Use one word at a time
Use two words at a time
Use three or more words at a time
Answer yes or no (verbally or by head movement)
Answer wh- questions
My child:
Always
Sometimes
Never
Has difficulty tolerating dressing or different clothing
Has difficulty tolerating new foods
Has difficulty tolerating bath time
Has difficulty tolerating brushing their teeth
Has difficulty falling asleep and staying asleep
Gets frustrated/aggressive when playing
What I love about my child is that they
blanks
*
.
My biggest concern about my child is that
blanks
*
.
Where did you hear about this group?
*
Our website
Social media
Friend/Family member
Through the outpatient clinic
Other
Additional Comments (please include relevant medical info if applicable):
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