SESLP - Parent Questionnaire

Behaviour and Motor Skills
How would you describe your child's physical development and motor skills? (e.g. walking, climbing, balance, eating skills, toilet training, finger dexterity etc.):*
Please describe your child's personality:*
Please list some of your child's favourite activities:*

Other Details & Information
What kinds of activities do you enjoy together, as a family?
We offer parent workshops throughout the year that are an important step in intervention for your child. Please list below any topics you may wish to see us cover (e.g. language development, speech-sound production, fluency, advocacy, social interaction/communication, etc.):
If you feel there is any additional information that could help us understand your child better, please tell us below:

Permissions
By signing below, I give permission to the BC Family Hearing Resource Society (BCFHRS) and the Surrey Early Speech and Language Program (SESLP) to provide services to my child and family.*
My Name

First NameLast Name
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.
Should be Empty:

	Check if services provided	Service Provider Name	Address	Phone Number	Email Address
Infant Development Program
Physiotherapy
Occupational Therapy
Visual Impairment Program
Speech Language Therapy
Supported Child Care/Development

Surrey Early Speech and Language (SESLP) Parent Questionnaire