Information Collection for M.Brazil, SLP

1
How did you learn about my services?* This field is required.
2
How old is your child? What grade are they in?* This field is required.
3
Please select the main challenge your child faces at the moment?* This field is required.With regards to Speech/Language Pathology or Reading Services
Please Select
They should be able to read, but struggle.
They have speech sounds that are mixed up, but are easy to understand.
They have speech sounds that are mixed up and are difficult to understand.
They have difficulties understanding and following instructions.
They are non-verbal.
They have very little speech output.
4
Please select a secondary challenge your child may face at the moment, if applicable?* This field is required.With regards to Speech/Language Pathology or Reading Services
Please Select
They should be able to read, but struggle.
They have speech sounds that are mixed up, but are easy to understand.
They have speech sounds that are mixed up and are difficult to understand.
They have difficulties understanding and following instructions.
They are non-verbal.
They have very little speech output.
Not applicable to my child.
5
Please select the main challenge your child faces at the moment?With regards to Speech/Language Pathology or Reading Services
Please Select
They are having a tough time learning letter sounds
They know their letter sounds, but struggle to read
Their speech doesn't sound right, they can be hard to understand
They don't seem to listen to or understand instructions
6
Please select a secondary challenge your child may face at this moment, if applicable?With regards to Speech/Language Pathology or Reading Services
Please Select
Not applicable
They cannot sit at a desk to do non-preferred work for more than 15 consecutive minutes without losing focus.
They are highly distractible.
They are emotional, and may or may not cry or have emotional outbursts.
They hit or lash out when frustrated.
They often do not listen, or retain instructions.
7
Please select the ones that describe your child:* This field is required.
They have a difficult time sitting at a desk to do non-preferred work for more than 15 minutes.
They can sit at a desk for more than 15 minutes but are highly distractible.
They are struggling in most areas of academics.
They seem to have difficulties listening and often do not retain information.
They have speech sounds that do not sound right, despite having received speech therapy before.
They are waiting to be assessed for Autism.
They have been diagnosed with Autism.
They are waiting to be assessed for ADHD.
They have been diagnosed with ADHD (and take medication).
They have been diagnosed with ADHD (and DO NOT currently take medication).
None of these describe my child
8
Does your child have any medical or educational issues that may be contributing to their learning or communication challenges? Please explain in detail.* This field is required.
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9
Please describe any tips, tricks, interventions, special help, or specialist appointments your child has received in their life so far. Please list the age at which the help was provided.* This field is required.
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10
Please describe your family's work and extracurricular activity schedule.* This field is required.If one parent (or more) works with IOCC, please list your work rotation. i.e. Shift 1 & 4 dayshift, Shift 2 days and nights.
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11
Does your child have allergies that would prevent them from entering a residence that is both dog-friendly, and peanut-friendly?* This field is required.
YESNO
12
Do you have private S-LP coverage through your work? * This field is required.This would be Manulife, Great West Life, etc. Please check with your insurance to learn your maximums per year.
YESNO
13
I am happy to provide a face-to-face consultation to any child age 4 to Grade 4. At your consultation appointment we will do a short baseline assessment to see if I have the resources needed to support your child. Consultation appointments are $150 for school-aged children and $200 for children 4-5 years of age. Your payment includes a 45-60 minute meeting, followed by a 20 minute online parent meeting at a later date to discuss recommendations, and a full written report. If I do not have the resources to meet your child's needs, our time together may end after the consultation. By selecting "yes" you acknowledge that a consultation appointment is mandatory, but therapeutic services may not be possible.* This field is required.
YESNO
14
I operate a small home office in Labrador City and have done this for the last 16 years. I see 22-24 children weekly, mostly after school and on Sundays. My services are not covered by MCP. They must be paid for by the parent. Some people have insurance for S-LP services through their workplace, and some do not. Do you understand that your services must be paid for by CREDIT CARD at each appointment?* This field is required.Session rates vary based on the frequency of the appointment and the goals of the child, but on average most appointments are $72-$98 per 30-45 minute session.
YESNO
15
While my fees are lower than the provincial average, they are still costly because children must attend weekly or biweekly, and the frequency is determined at the first appointment based on an assessment of needs. Do you understand that your child may need to come weekly or biweekly at a ?
YESNO
16
Parent's name* This field is required.
First Name
Last Name
17
Child's name* This field is required.
First Name
Last Name
18
Email* This field is required.Please choose an email address that you check OFTEN!
example@example.com
Should be Empty: