Home
Services
Meet our Speech Pathologist
Fees
FAQs
Useful Links
What to Bring to Your Session
Contact us
Address , Phone, Email
Parent Online Questionnaire
Wanneroo Area Speech Pathology Online Questionnaire.
Please do not complete this form until an appointment has been booked.
Child's Details
*
Indicates required field
Name of Child
*
Date of Birth
*
Primary Home Address/es of Child
*
Gender
*
Male
Female
Other
School Year
*
School and Teacher Name
*
Please describe your child's personality and attributes
*
List your child's hobbies, interests & favourite pastimes
*
Family Details
Names of parents/ caregivers
*
Contact Address/es
*
Phone Numbers
*
Please list all phone numbers
E-mail address/es
*
Private Health Fund Details
*
Languages Spoken at Home
*
Details of Siblings
*
Details of pets
*
Days and times that you are available to bring your child
*
Referral Information and Health/Medical Information
Why your child needs a speech pathology assessment and any other developmental concerns
*
Please provide information regarding any pregnancy, birth, medical, health or accidents
*
Please provide details of vision and hearing skills and whether these have been formally tested
*
Provide details of milestone development eg when crawled,walked, toilet trained - any concerns
*
Please provide details of other specialists or agencies involved
*
Speech, Language & Literacy Development
Details of any family history of, speech, language, learning, attentional or autism issues
*
Details of speech and language development e.g. when said first words, when said 2 words, whether speech and or language seemed to go backwards, when first became concerned etc
*
Describe the type of difficulties your child is experiencing i.e. speech/articulation; fluency/stuttering; comprehension or listening difficulties; expressive language - vocabulary,grammar,story-telling/discourse difficulties or reading, spelling , writing difficulties etc
*
Details of any speech pathology assessment results or intervention provided previously
*
Behaviour and Social Interaction
Please comment on your child's behaviour at home and in other settings
*
Please comment on your child's social and conversational skills and ability to make friends and play with other children.
*
Please comment on how your child is coping at school - academically, socially and emotionally
*
Please provide any other information that you feel may be useful in understanding or working with your child.
*
Thank you for taking the time to complete this questionnaire. Please press the submit button to forward to our office.
Submit
Home
Services
Meet our Speech Pathologist
Fees
FAQs
Useful Links
What to Bring to Your Session
Contact us
Address , Phone, Email
Parent Online Questionnaire