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ยป Client Intake Form
Client Intake Form
1
Start
2
Complete
Client Name
*
Date of Birth
*
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
1
2
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31
Year
Year
1992
1993
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2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
Gender
*
- Select -
Male
Female
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
Is the child currently receiving services from any of the following agencies or professionals?
Sunnyhill Health Centre for Children
BC Children's Hospital
Centre for Child Development
School District
ABA consultant
Vision/Hearing Specialist
Speech-Language Pathologist
Occupational Therapist
Physical Therapist
Other
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
*
-Select-
0-20
21-50
51-100
101-150
151-300
301-500
501+
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?