Sounds difficulties enquiry - WordSteps Speech Therapy

Sound difficulties enquiry

In order to make the most out of our time, please fill out the questions below so that I can best serve you during our conversation. I will read your responses and prepare in advance for our time together.

I am looking forward to talking with you! When it is time for our call, it is YOUR responsibility to call me at the phone number that will be provided in your confirmation email after I receive this form.

If you need to reschedule, you may email me at least 48 hours in advance and we can reschedule.

Enquiry for difficulties with sounds only

Name*

Surname*

Your Email*

Your Number*

Your City*

Is this your first visit?

YesNo

How did you hear about me?

RecommendationGoogle searchFacebook

What is the main reason that you want to be in touch with me:

My child has no soundsMy child’s speech is totally unintelligibleMy child has difficulties with few soundsMy child is also bilingual (if so please state what are the languages)

Briefly describe your child (age, gender, and any other details you think I should know

Age

Gender

Does he/she go to nursery or school?

yesno

Please describe your child’s personality and if he/she is frustrated by his/her communication.

What kind of strategies do you use?

Translating for others, but I understandCorrect my child when words are not pronounced correctlyRepeat and remodel without correctiondistract my childOther (please explain)

What kind of support do you need from me? (Check all that apply) *

AdviceRecommendationsProblem-SolvingCreative IdeasBrainstormingTherapy

What are your biggest struggles or concerns you have about your child currently? *

What do you hope to gain/achieve from our session together? *

Any other questions?

This session is for brainstorming and mentoring and intended to point you toward resources you may need. By checking this box, you understand that this session is not a substitute for in-person, face-to-face, speech therapy diagnosis and treatment.

I accept privacy policy as GDPR/2016

* Means the field is required

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