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COMMUNICARE SPEECH THERAPY SERVICES

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We are happy to connect with you via phone, email or in person. Please fill out the form below and we will contact you.

We Would love to hear from you!

* Indicates required field

Name of Person Completing this Form *

First

Last

(ie. parent, caregiver, client, legal guardian)

Relationship to Client *

If you are the client, please indicate "self"

CLIENT INFORMATION:

Client's Full Name *

Preferred Name (if different) *

Date of Birth (MM-DD-YYYY) *

Gender/Pronouns *

Primary Language Spoken at Home *

Other Languages Spoken *

CONTACT INFORMATION:

Street Address *

City, Province *

Postal Code *

Primary Phone Number *

Additional Phone Number *

Email *

Preferred Method of Contact *

Phone Text Message Email

MEDICAL / DEVELOPMENTAL HISTORY:

Please note: while the medical/developmental information below is not required for the initial contact form, providing this information at the start of this process helps Communicare Speech Therapy to gain a full picture of the Client from the outset of our communication together.

Current Diagnoses (if any) *

If the client does not have a current diagnoses, type "none."

Medications (if applicable) *

Relevant Medical History *

E.g. hearing, vision, neurological concerns

REASON FOR REFERRAL / AREAS OF CONCERN:

Please check all that apply, and briefly describe in the space below.

Please check all that apply *

Speech clarity / articulation Language (understanding or expressing) Stuttering / fluency Voice quality Social communication / pragmatics Oral myofunctional therapy (OMT) Swallowing / feeding Other (please specify below)

If "other," please specify *

Please describe any concerns as indicated above above. *

Please describe your main concerns or goals for therapy. *

PREVIOUS ASSESSMENTS OR SERVICES:

Has the client received speech therapy before? *

Yes No

If yes, when and where? *

Has the client received other relevant therapies or support services (if yes, please describe)? *

E.g. OT, PT, counselling, special education

Are copies of past reports available? *

Yes No Unsure

ADDITIONAL INFORMATION:

Is there anything else you would like us to know about the client or your concerns? *

Submit

Communicare Speech Therapy Services

Kelowna, BC

Phone: 250-764-3622
Email: [email protected]

Communicare Speech Therapy Services | Making the Connection
Kelowna, BC

Home
Who We Are
What We Offer
- For Children
- For Adolescents & Adults
Fees & Resources
- Fees
- Resources
FAQ
Contact