SESLP - Parent Questionnaire

  • Surrey Early Speech and Language (SESLP) Parent Questionnaire

  • Please fill in this form. This information is entirely confidential.

    The information requested on this form will assist this program in understanding your family's concerns regarding your child's communication.  If we can help filling out this form, please call us.

     

    (Kindly fill the form in English only)

  • Family Information & Personal History

  • Sex:*

  • Please include information about all primary caregivers.

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  • Does this child have any siblings? If so, how many?
  • Do you have a Family Doctor or a Nurse Practitioner?*
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  • Do you have a Nurse Practitioner?*
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  • Do you have a pediatrician?*
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  • Do you have a social worker assigned to your family?*
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  • If you have any emergency contacts for your family, please enter their information below:

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  • Our program strives to respect diversity. If you think it will help us better serve your family, please provide the following optional information:

  • Do you prefer to use an interpreter?*
  • Please check if any of these apply to your family. a. In the country known as Canada

  • b. In the country of your origin

  • Medical Information

  • Birth History:

  • Were there any complications at birth? (eg. Cleft palate, Emergency C-Section, Cord around neck, Breathing, etc.)*
  • Did your child have any pre-natal exposure to these substances? Please check all that apply.
  • Are your child's immunizations up to date?*
  • Does your child have any allergies or sensitivities?*
  • Does your child have any serious illnesses or chronic medical conditions?*
  • Has your child had any serious illnesses, accidents or hospitalizations?*
  • Has your child had any of the following examinations done? Please check all that apply.*

  • Hearing Ability

  • Was your child's hearing screened at birth?*
  • Has your child's hearing been tested in a sound proof booth?*
  • Test Results*
  • Has your child had frequent ear infections?*
  • Has your child ever had to have tubes in his/her ears?*

  • Visual Ability

  • Has your child’s vision been tested by an Optometrist or Ophthalmologist?*
  • Test results*

  • Description of Communication Skills

  • Speech and Language Milestones

  • Did your child babble during the first six months?*
  • Did your child ever begin to develop speech and then slow down or stop talking?*
  • Was your child using his/her first meaningful words by 12 to 15 months?*
  • Was your child putting two or more words together by 20 to 26 months? (e.g. "mommy do", "can go")*
  • What does your child do most now, to communicate? Check ALL that apply.*

  • Behaviour and Motor Skills

  • Support Services

  • Does your child currently attend preschool, daycare, or childcare services?*
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  • Is your child receiving ongoing services from any other individuals or programs? Please check all that apply:*
  • Rows
  • Are there any people in your life or community supports or resources that you have found helpful to your family?

  • Other Details & Information

  • Permissions

  • If you have any questions about how to fill in this form, please contact the Surrey Early Speech and Language Program at 604-498-1833, or email info@seslp.org. You can also visit our office at #205 - 10330 152nd Street, Surrey, BC, V3R 4G8.

     

     

    FREEDOM OF INFORMATION AND PROTECTION OF PRIVACY ACT (FOIPPA): The information requested on this form is collected under the authority of section 26(c) of the Freedom of Information and Protection of Privacy Act (FOIPPA). The information provided will be used only to facilitate the operation of our services/programs and is in compliance with the FOIPPA. If you have any questions about the collection of your personal information, please contact us. Our head office address is 15220, 92nd Avenue, Surrey, BC V3R 2T8. You can also contact us by phone at 604-584-2827 (or toll-free at 1-877-584-2827), or by email at info@bcfamilyhearing.com.

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