Training and Support for Complex Communications Needs

Client Intake Form

1 Start 2 Complete

Client Name *

Date of Birth *

Month

Day

Year

Gender *

Nickname

Diagnosis (if known)

Parent(s)/Guardian(s) *

Address *

City, Province, Postal Code *

Cell Phone Number *

Enter numbers only, no spaces, no dash (e.g. 5555555555)

Home Phone Number

Enter numbers only, no spaces, no dash (e.g. 5555555555)

Work Phone Number

Enter numbers only, no spaces, no dash (e.g. 5555555555)

Email #1 *

Email #2

Physician Name *

Physician Phone Number

Physician Address

Provide name of school district and/or professionals currently providing services

How did you hear about Chickadee AAC?

Describe in your own words the nature of your concerns about the child's communication skills and/or the primary referral reasons *

Does the child currently use any equipment? (communication device, walker, wheelchair, etc.) Describe

Does the child have a history of ear infections, tubes, etc. or use hearing aides?

Yes

No

Describe

How many words does the child say *

Does the child produce sentences of the following length

2 words

3 words

4 words

5+words

What percentage of the child's speech do you understand? * %

How well do people outside of the family understand the child's speech? * %

If the child is not using words, how does he/she communicate

What are the child's strengths? *

What are the child's favourite activities? *

Is there anything else that is important for us to know about the child?

Training and Support for Complex Communications Needs

Client Intake Form

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Forms & Docs

Useful Links

Training and Support for Complex Communications Needs

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Client Intake Form

Chickadee Around the Web

Forms & Docs

Useful Links

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