• 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

  • Child's Birthdate*
  • Sex:*

  • Please include information about all primary caregivers.

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  • Does the child have any siblings? If so, how many?*
  • Month and Year of birth*
  • Month and Year of birth*
  • Month and Year of birth*
  • Month and Year of birth*
  • Month and Year of birth*
  • Do you have a Family Doctor or 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, Cord around neck, Breathing, Heart rate, 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?*
  • Currently, does your child have any serious illnesses or chronic medical conditions?*
  • In the past, 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.*

  • Date of medical exam*
  • Date of neurological exam*
  • Date of allergy testing*
  • Date of psychological assessment*
  • Date of speech language assessment*
  • Date of Ear, Nose & Throat exam*
  • Date of occupational therapy evaluation*
  • Date of physiotherapy evaluation*
  • Date of Pediatrician exam*
  • Date of "other" examination/evaluation*

  • Description of Communication Skills

  • Speech and Language Milestones

  • Did your child babble during the first six months?*
  • Was your child using their first meaningful words by 12 to 15 months?*
  • Did your child ever start to babble or say meaningful words and then did not develop new sounds/words and/or stop using these sounds/words?*
  • Was your child putting two or more words together by 20 to 26 months? (e.g. "mommy do", "can go")*
  • Does your child stutter? (has trouble getting first word out, repeat the first sounds or part of a word, start a sentence and change to start a different way, etc.)*
  • When did the stuttering begin*
  • Please check the types of stuttering you have noticed in your child (check all that apply)*

  • What does your child do most now, to communicate? (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 by an Audiologist?*
  • 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*

  • Behaviour and Motor Skills

  • Have you noticed any disruptive behaviors that you are concerned about or do not appear to be age appropriate:*
  • How much time does your child spend on the screen in a day? (this includes phone, tablet, iPad, TV, apps like YouTube, etc.)*

  • Support Services

  • Does your child currently attend preschool, daycare, or childcare services (e.g. Strong Start, etc.)?*
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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

  • By signing below, I give permission to the Society for Families of Deaf and Hard of Hearing Children (SFDHHC) and the Surrey Early Speech and Language Program (SESLP) to provide services to my child and family (to be signed by parent or legal guardian only)*
  • Today's date:

  • 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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