Email Address
Consent to contact by email: Consent to contact by email: Yes No
Child's name (first, middle & last)
Date of birth
Gender: Gender: Male Female Other
Child's address (house/unit #, street name & direction)
Postal Code
Health Card #
Primary Language of child: Primary Language of child: English French Other
Other Language (please specify)
Legal Guardian
Work # (include extension)
Home/Cell #
Address, if different from above (house/unit #, street name & direction)
Primary Parent/Caregiver
Primary Parent/Caregiver Relationship
Secondary Parent/Caregiver
Secondary Parent/Caregiver Relationship
Name of Child Care Centre
Starting School in September? Starting School in September? Yes No Not sure
School Name
Physician
Other Specialists
Has the child previously received Speech and Language services? Has the child previously received Speech and Language services? Yes No
If yes, name of SLP
Referral Initiated by
How did you hear about the service?
Please describe your concerns
Does your child have any severe allergies/health issues that we need to be aware of?
Will anyone attending this appointment require assistance to access our services? (wheelchair/bus tickets)
When is the best time to contact you?
