Speech and Language Form -

Speech and Language form

Speech and Language Form - Kent

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Child's name

Child's date of birth

Parent's / carer's name(s)

Address

NHS local trust

Gender

Ethnicity

Home language

Telephone number

Details of people living at home (e.g. parents, carers, siblings)

Personal interests - please list any items or activities that will motivate your child

Strengths of your child

Main concerns

Attention skills (e.g. ability to concentrate on activities)

Understanding of language (e.g. following instructions, understanding concepts and vocabulary)

Using language (e.g. talking, naming items, using sentences)

Social communication (e.g. ASD diagnosis, lack of eye-contact, difficulties talking to others, limited play skills, unusual and repetitive language)

Stuttering/stammering (e.g. repeating or prolonging words, syllables or sounds)

Articulation/phonology difficulties (e.g. ability to produce sounds correctly, intelligibility)

Eating and drinking difficulties

Alternative Augmentative Communication (e.g. AAC – Makaton, PECS, communication boards, high tech AAC tablets)

What are your hopes and expectations from Speech and Language Therapy?

Year group

Date of admission to school/nursery

Details of previous schooling e.g. nursery attended

Please check any of the boxes below if any family members have one of the following

Speech / language difficulties

Literacy difficulties / dyslexia

Stammer

Hearing

Learning difficulties

None of the above

Were there any complications with the pregnancy or birth? If yes, please give details

At approximately what age did your child achieve the following milestones? Sit:

Crawl

Walk independently

Run

Dry during the day

Dry at night

Feed self

Dress self

Does your child have a medical diagnosis? If yes, please give details

Do you have concerns regarding your child's hearing?

Yes

Has your child had a hearing test in the last 3 months?

Yes

Has your child had a history of ear infections?

Yes

Has your child had a history of frequent colds

Yes

Has your child had a history of seizures

Yes

Has your child had a history of allergies

Yes

Other

Has your child been seen by or referred to any of the following professionals?

Paediatrician

Ear Nose and Throat Surgeon

Cleft Team

Physiotherapist

Occupational Therapist

Clinical Psychologist

Educational Psychologist

None of the above

Did your child vocalise frequently as a baby, particularly between 6 – 12 months?

Yes

Did your child babble e.g. baba; dada?

If so, when?

Did your child use varied babble with different consonant sounds (e.g. bada; galagala)?

Yes

When did your child produce first recognisable words (e.g. “mummy”, “daddy”, “ball”, “duck”)?

When did your child join two words together (e.g. “more juice”, “pop bubble”, “hello daddy” etc)?

When did your child join three-four words together (e.g. “mummy I want water”)?

Do you have concerns about your child’s speech sounds? If so, what sounds specifically?

Can you understand your child when they talk?

Yes

How many words do you think your child can say?

Does your child sometimes find it hard to name an item or may use a similar word to describe it?

Yes

Does your child make some grammatical errors when they are talking (e.g. wrong pronoun)?

Yes

Does your child follow instructions (e.g. go and get your coat?)

Yes

Does your child understand most of the vocabulary that you use?

Yes

Does your child know basic concepts such as numbers, shape, size (big/little), prepositions (in/on/under)?

Yes

Does your child often get frustrated? If so, why?

Yes

Does your child find it hard to attend to a task?

Yes

Does your child fidget or find it difficult to sit down?

Yes

Does your child find it hard to interact with peers?

Yes

Does your child have limited eye-contact?

Yes

Does your child find it hard to make friends?

Yes

Are you concerned about your child’s social communication skills?

Yes

Please provide any information that you feel is necessary for the Therapist to know

Please tick box to show whether you give consent to the following:

I agree for my child to be seen for an assessment and/or therapy by The Children's Wellness Centre Speech and Language Therapy Team. I understand I can withdraw my consent at any time.

I agree for any relevant information about my child to be shared between relevant professionals (e.g. school, doctor, psychologist, NHS therapist etc) in confidence, in the best interest of the child’s development.

I am aware that session notes will be owned and stored by my child's individual therapist

I understand that audio, video or photographic records may be made as part of my child’s assessment and therapy.

I agree to the use of electronic communication. All documents will be password protected and saved as a PDF.

Terms and Conditions of Therapeutic Services within The Children’s Wellness Centre. By ticking the following checkbox, the client is accepting the terms and conditions below

Our Therapists will adopt a client-led approach and will offer advice, support and options for next steps, but it is the client’s responsibility to decide what is right for their child

The Therapist that you are seeing is DBS checked and holds Professional Indemnity insurance, practicing within the framework of their profession and registrations

The Therapist reserves the right not to accept a referral, terminate an assessment or not to circulate an assessment report if the referral appears to be outside their area of expertise or the client fails to comply with the terms and conditions set out in this agreement

Any information shared by the client with the Therapist and The Children's Wellness Centre is treated as confidential, unless a safeguarding concern is disclosed. Client details will not be passed onto other parties unless specifically requested e.g. forwarding reports to other professionals and schools

Payment for Speech and Language Assessments and Screeners is required at the time of booking, in order to secure the space. Payment for weekly Therapy sessions is due prior to each session

Payment is usually made via BACS and clients will receive an email invoice once they have booked. Your Assessment or Screener is confirmed on receipt of payment

Please note we have a 48-hour cancellation policy. Late cancellations (not within 48-hours) and missed appointments, will still need to be charged in full

For any clients claiming through their health insurance, payment must be settled directly with The Children’s Wellness Centre by the client and can be reclaimed via their insurance provider, using the receipt we can provide

If the client has a complaint against the Therapist that they are seeing, they must inform The Children’s Wellness Centre, emailing jake@childrenswellnesscentre.co.uk immediately and all efforts will be made to resolve and settle any disputes, without litigation