Whiz Kids — New Client Intake

Start with Whiz Kids — New Client Form

Thanks for choosing to go ahead with Whiz Kids Therapy. This form gives Alex (Speech Pathologist) what she needs to plan the right assessment for your child. It takes about 10 minutes. You'll also receive a Halaxy sign-up invitation for our practice records.
Parent and Child Details
Parent/Guardian full name

First NameMiddle NameLast Name
Second parent/guardian name

First NameMiddle NameLast Name
Child's full name

First NameMiddle NameLast Name
Child's date of birth

MonthDayYear
Date
Email
example@example.com
Mobile
Please enter a valid phone number.Format: (000) 000-0000.
Home address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
School/childcare name and teacher's name
Is your child at one of our partner schools?
School Liaison and Funding
May we liaise with the teacher/school?
Funding type

Other
Plan manager / billing contact details
Concerns and History
What are you concerned about?

Other
Tell us more — what do you notice, when did it start, what worries you most?
What does the school/teacher say (if anything)?
Has your child had speech pathology or other assessments before?
If yes — who, when, and please email any reports to alexandra@whizkidstherapy.com
Any of the following apply?
Early history (helps us understand your child's presentation)
Birth and first three years — anything notable? (pregnancy/birth, milestones, ear infections, talking late, feeding)
Languages spoken at home
Practical Details and Consent
Where could sessions happen?
Best times generally
Anything else Alex should know? (interests, motivators, siblings, custody/consent arrangements)
How did you hear about us?
Consent and service understanding
Full name

First NameMiddle NameLast Name
Date

MonthDayYear
Date
Should be Empty:

Start with Whiz Kids — New Client Form

Parent and Child Details

School Liaison and Funding

Concerns and History

Early history (helps us understand your child's presentation)

Practical Details and Consent