Apheleia Speech - Initial Questionnaire

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Contact First Namehidden

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Contact Last Namehidden

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Contact Form Emailhidden

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Contact Form Phonehidden

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Contact Form Partnershiphidden. Pass through partnership details (if applicable). Eg. DSAP, FSCD, etc

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Contact Form URL

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Existing Notion Client Page IDNOTE: should never use this as we should send all clients to the regular contact form to fill out first! Automations will likely screw up if we did.

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Are you looking for speech therapy for a CHILD or ADULT?* This field is required.

Child

Adult

Name of the Child/Adult needing Speech Therapy* This field is required.

First Name

Last Name

What is your relationship to {Name_first_last_ChildAdult[1]}?* This field is required.

Mother

Father

Relative

Grandparent

Myself: I am applying for myself

Child of the adult needing therapy

Spouse

Other

{Name_first_last_ChildAdult[1]}'s Date of Birth* This field is required.of the Child/Adult needing Speech Therapy

Year

Month

Day

Is {Name_first_last_ChildAdult[1]} male or female?* This field is required.

Male

Female

Other

What is your main concern(s) for {Name_first_last_ChildAdult[1]}?* This field is required.Select ALL that Apply

Late Talker (Early Language)

Pronunciation / Speech Clarity (Articulation)

Expressing Thoughts and Needs: (Expressive language: Vocabulary, Grammar, Storytelling, Making Requests, etc.)

Understanding What You Say (Receptive language: Answering questions, Following Directions, etc)

Stuttering / Stammering (Fluency)

Literacy / Reading & Writing / Dyslexia

Social Skills / Interacting with Peers (Pragmatics)

Attention and Focus / ADHD and ADD (Executive Functioning)

Voice (Raspy Voice, Hoarseness, Nasal Voice, etc.)

Other

What percentage of {Name_first_last_ChildAdult[1]}'s spoken words do YOU understand?* This field is required.

N/A - my child is not yet using words

25%

50%

75%

95-100%

What percentage of {Name_first_last_ChildAdult[1]}'s spoken words would a LESS FAMILIAR adult understand ?* This field is required.e.g. a friend or family member who only sees your child occasionally

N/A - my child is not yet using words

25%

50%

75%

95-100%

What is your main concern(s) for {Name_first_last_ChildAdult[1]}?* This field is required.Select ALL that apply

Stroke (Aphasia, Apraxia, Dysarthria)

Accent Modification

General Communication Coaching (eg. Public Speaking, Work Communication, Confidence)

Swallowing, Choking, Gagging, (Dysphagia)

Pronunciation / Speech Clarity (Articulation)

Stuttering / Stammering (Fluency)

Literacy/Reading or Dyslexia

Expressing thoughts and needs: (expressive language: vocabulary, grammar, story telling, making requests, etc)

Understanding what is said (receptive language: answering questions, following directions, etc.)

Social Skills / Interacting with Peers (pragmatics)

Attention and Focus / ADHD and ADD (executive functioning)

Gender Diverse Voice Services (feminization, masculinization and/or neutral)

Voice (Raspy voice, Hoarseness, Nasal voice etc.)

Voice coaching (For Singing, Public Speaking, etc.)

Other

Briefly explain the main difficulties {Name_first_last_ChildAdult[1]} is experiencing in their daily life.* This field is required.

Any relevant or suspected diagnoses for {Name_first_last_ChildAdult[1]}?Child: Developmental Delay, ASD, Apraxia, Dyslexia, Ear infections, Hearing impairment, etc Adult: parkinsons, stroke/aphasia, dementia, ALS, etc

Do you have any concerns about {Name_first_last_ChildAdult[1]}'s hearing?* This field is required.

Yes

Unknown

Please elaborate your hearing concerns.* This field is required.

How is {Name_first_last_ChildAdult[1]} most commonly communicating with you?* This field is required.Select ALL that apply

Full Sentences

2 to 3 Word Combinations

Single Words / Sounds

Not Speaking

Points and Gestures

AAC Device (e.g. iPad or Communication Board)

Feel free to tell us more about how they communicate with you (optional).

Has {Name_first_last_ChildAdult[1]} had a Speech Therapy assessment or services in the past?* This field is required.

YESNO

Please briefly describe your experience with previous services.* This field is required.Diagnosis, goals, progress, year/date & duration of therapy, etc

What languages are spoken in the home?* This field is required.Select ALL that apply

English

French

Other

Are there any special custody or decision making arrangements for {Name_first_last_ChildAdult[1]}?Why we ask: if you decide to proceed with services, we will need consent from all parties. Eg. Separated/Divorced parents, guardianship, power of attorney, substitute decision maker, enacted personal directive.

YESNO

What are {Name_first_last_ChildAdult[1]}'s interests and/or hobbies?* This field is required.We want to create a fun & engaging therapy experience! Eg. sports/activities, art, video games, gardening, cooking, card/board games, profession, TV shows, 'things' (eg. trucks, ponies, dinosaurs), etc

What days would you be available for the weekly Zoom therapy session?* This field is required.Select ALL that apply

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

When are you available on Mondays?* This field is required.Select ALL that apply

Before School / Work

During the Day

After School / Work

When are you available on Tuesdays?* This field is required.Select ALL that apply

Before School / Work

During the Day

After School / Work

When are you available on Wednesdays?* This field is required.Select ALL that apply

Before School / Work

During the Day

After School / Work

When are you available on Thursdays?* This field is required.Select ALL that apply

Before School / Work

During the Day

After School / Work

When are you available on Fridays?* This field is required.Select ALL that apply

Before School / Work

During the Day

After School / Work

When are you available on Saturdays?* This field is required.Select ALL that apply

Morning

Afternoon

Evening

When are you available on Sundays?* This field is required.Select ALL that apply

Morning

Afternoon

Evening

Do you have Google Drive (or Gmail)?* This field is required.If not, no worries! We can help with that later. You'll use it for collaboration with your therapist.

Yes

What is your Google Drive/Gmail Email?* This field is required.

example@example.com

How did you hear about us?* This field is required.

Facebook

Google

Instagram

Doctor Referral

Friends/Family (Word of Mouth)

DSAP

UofC CME Program

MNO - Métis Nation of Ontario

Quest 4 Change

Other

Do YOU have any questions for us?* This field is required.We'll make sure these get answered!

YESNO

What are your questions?* This field is required.

Do you have any concerns about Online Speech Therapy or Speech Therapy in general?* This field is required.We'll make sure these get addressed!

YESNO

Mention your concerns here:* This field is required.

How would you like us to answer your questions and/or concerns?* This field is required.

Text Message

Phone Call

Zoom call

Your Email* This field is required.