用心說語言治療所療育預約單｜兒童-成人語言治療

您好：

歡迎填寫用心說語言治療所預約表單。

填寫預約表單前，以下治療所介紹以及預約注意事項煩請閱讀。

>> 用心說語言治療所地址：台北市士林區中山北路五段811巷23號一樓

>> 我們為自費單位，可申請早療補助。

>> 有任何疑問，請加Line官方帳號洽詢： https://lin.ee/9Fqo8h3

Hello,

Before filling out the appointment form, please take a moment to read the following clinic information and important notes regarding appointments.

>>Address: 1F., No. 23, Ln. 811, Sec. 5, Zhongshan N. Rd., Shilin Dist., Taipei City
>>Payment: Private-pay services only.
>>For any questions, please contact us via our official LINE account: https://lin.ee/9Fqo8h3
語言治療費用說明
療育為長久的合作和信任關係，在課程開始前，我們期待可以和您有以下約定:

孩子姓名Child's Name*
孩子生日Child's DOB*

YearMonthDay
Today's date

MonthDayYear
Date
孩子年齡Child age
性別 Gender*

女Female男Male
孩子目前就讀年級Current grade level*

尚未上學Not yet in school幼幼班 Nursery Class小班 Pre-K中班 K1大班 K2小一Gr. 1小二 Gr. 2小三Gr. 3小四 Gr. 4小五 Gr. 5小六 Gr. 6其他
孩子目前就讀年級Current grade level *
聯絡人姓名Contact person’s name*
聯絡人和個案(孩子)的關係Relationship to the child/client*
聯絡人的手機號碼 Contact person’s mobile number*
聯絡人 Line ID? Contact person's Line ID*
想看到孩子在哪方面的進步？如：語言表達、構音、口吃、閱讀理解或互動技巧等。What areas of improvement would you like to see for your child?(e.g., language expression, articulation, stuttering, reading comprehension, or interaction skills)

如需做吞嚥治療或想先學一些誘發語言表達的技巧在家裡練習，也請特別註明，我們會再和您討論。If your child needs swallowing therapy or if you would like to learn strategies to encourage language expression at home, please specify this as well. We will follow up with you to discuss further.
必答*
希望安排的時段 (目前週末時段待排需半年以上）/ Preferred time slot (Weekend appointments may have a wait time of 6+ months)

＊＊＊目前仍有周間下午3:00前時段可以立刻安排，若時段可以，可以直接在官方line告知，謝謝＊＊＊
＊＊＊Weekday slots before 3:00 PM are currently available for immediate scheduling. If this time works, please inform us via our official LINE account. Thank you.＊＊＊
必答*

週一上午週一下午週一晚上週二上午週二下午週二晚上週三上午週三下午週三晚上週四上午週四下午週四晚上週五上午週五下午週五晚上週六上午週六下午週日上午週日下午
是否持有診斷證明書、綜合報告書或身心障礙手冊 If you have any of the following documents, please check all that apply*

是，診斷說明書 Medical diagnosis certificate是，綜合報告書 Comprehensive/ Multidisciplinary evaluation report是，身心障礙手冊 Disability identification card否，還沒有看診或評估過 Has not received any diagnosis or evaluation yet否，但目前正在排評估中 Currently waiting for evaluation
目前有在接受的治療課程（如職能治療、物理治療、心理治療等）Current ongoing therapies (e.g., occupational therapy, physical therapy, psychological therapy, etc.)
在哪裡得知我們？ How did you hear about our clinic?*

家長/ 親友介紹 Parent / Friend referral醫療院所介紹 Referral from medical institution福利機構轉介 Referral from social welfare agency學校介紹 School referral網路搜尋 Online search其他
其他想要告訴我們的事？Additional notes or information
請加入Line官方帳號，並主動傳訊告知已填預約表單，讓我們知道您是哪一位孩子的聯絡人

After completing the appointment form, please add our official LINE account and send a message to inform us, so we know which child you are contacting us for.
加入官方 Line/ Add our official LINE account: https://lin.ee/LQujX9a傳一個貼圖或文字訊息(如hi)給我們，才會看到您們的帳號/ Please send us a sticker or a text message (e.g., “Hi”) so that we can see your account.
請記得按下面的「送出」按鈕，我們才會收到您填寫的表單/ Don’t forget to press the “Submit” button below to send us your form.*

好的！Got it!
確認不是機械人*
Should be Empty:

療育為長久的合作和信任關係，在課程開始前，我們期待可以和您有以下約定:

想看到孩子在哪方面的進步？如：語言表達、構音、口吃、閱讀理解或互動技巧等。What areas of improvement would you like to see for your child?(e.g., language expression, articulation, stuttering, reading comprehension, or interaction skills)

希望安排的時段 (目前週末時段待排需半年以上）/ Preferred time slot (Weekend appointments may have a wait time of 6+ months)

請加入Line官方帳號，並主動傳訊告知已填預約表單，讓我們知道您是哪一位孩子的聯絡人