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Initial Questionnaire
Your answers will help us match you with the right therapist.
19
Questions
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1
Contact Form ID Number
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2
Contact First Name
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3
Contact Last Name
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4
Contact Form Email
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5
Contact Form Phone
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6
Contact Form Partnership
hidden. Pass through partnership details (if applicable). Eg. DSAP, FSCD, etc
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7
Contact Form URL
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8
Existing Notion Client Page ID
NOTE: 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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9
Are you looking for speech therapy for a
CHILD
or
ADULT?
*
This field is required.
Child
Adult
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10
Name of the
Child/Adult
needing Speech Therapy
*
This field is required.
First Name
Last Name
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11
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
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12
{Name_first_last_ChildAdult[1]}'s
Date of Birth
*
This field is required.
of the
Child/Adult
needing Speech Therapy
Year
Please Select
01 | January
02 | February
03 | March
04 | April
05 | May
06 |June
07 |July
08 | August
09 | September
10 | October
11 | November
12 | December
Please Select
Please Select
01 | January
02 | February
03 | March
04 | April
05 | May
06 |June
07 |July
08 | August
09 | September
10 | October
11 | November
12 | December
Month
Day
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13
Is
{Name_first_last_ChildAdult[1]}
male or female?
*
This field is required.
Male
Female
Other
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14
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
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15
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
0%
25%
50%
75%
95-100%
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16
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
0%
25%
50%
75%
95-100%
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17
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
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18
Briefly explain the main difficulties
{Name_first_last_ChildAdult[1]}
is experiencing in their daily life.
*
This field is required.
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19
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
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20
Do you have any concerns about
{Name_first_last_ChildAdult[1]}'s
hearing?
*
This field is required.
Yes
No
Unknown
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21
Please elaborate your hearing concerns.
*
This field is required.
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22
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)
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23
Feel free to tell us more about how they communicate with you (optional).
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24
Has
{Name_first_last_ChildAdult[1]}
had a Speech Therapy assessment or services in the past?
*
This field is required.
YES
NO
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25
Please briefly describe your experience with previous services.
*
This field is required.
Diagnosis, goals, progress, year/date & duration of therapy, etc
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26
What languages are spoken in the home?
*
This field is required.
Select ALL that apply
English
French
Other
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27
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.
YES
NO
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28
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
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29
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
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30
When are you available on Mondays?
*
This field is required.
Select ALL that apply
Before School / Work
During the Day
After School / Work
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31
When are you available on Tuesdays?
*
This field is required.
Select ALL that apply
Before School / Work
During the Day
After School / Work
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32
When are you available on Wednesdays?
*
This field is required.
Select ALL that apply
Before School / Work
During the Day
After School / Work
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33
When are you available on Thursdays?
*
This field is required.
Select ALL that apply
Before School / Work
During the Day
After School / Work
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34
When are you available on Fridays?
*
This field is required.
Select ALL that apply
Before School / Work
During the Day
After School / Work
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35
When are you available on Saturdays?
*
This field is required.
Select ALL that apply
Morning
Afternoon
Evening
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36
When are you available on Sundays?
*
This field is required.
Select ALL that apply
Morning
Afternoon
Evening
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37
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
No
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38
What is your Google Drive/Gmail Email?
*
This field is required.
example@example.com
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39
How did you hear about us?
*
This field is required.
Facebook
Google
Instagram
Doctor Referral
Friends/Family (Word of Mouth)
Other
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40
Do YOU have any questions for us?
*
This field is required.
We'll make sure these get answered!
YES
NO
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41
What are your questions?
*
This field is required.
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42
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!
YES
NO
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43
Mention your concerns here:
*
This field is required.
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44
How would you like us to answer your questions and/or concerns?
*
This field is required.
Text Message
Email
Phone Call
Zoom call
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45
Your Email
*
This field is required.
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