Group Program Registration

Current Program Registration

Registration is now open for our Winter 2023 Group Programs. Complete the following form to register now.

Please select the group you would like to register for: *

Kids Chat (Age 5 - 8)
Awesome Alternative Communicators (Age 6 - 10)
BLUE Social Language Breakfast Club (Age 8+)
RED Social Language Breakfast Club (Age 15+)
Adult Social Language Connection (Age 21+) **LIMITED AVAILABILITY**

Select a group for more information.

Kids Chat - 6 Lessons

TOTAL COST: $540.00 (made in two installments of $270.00)

Awesome Alternative Communicators - 6 Lessons

TOTAL COST: $540.00 (made in two installments of $270.00)

BLUE Social Language Breakfast Club - 14 Lessons

RED Social Language Breakfast Club - 14 Lessons

Adult Social Language Connection - 9 Lessons

TOTAL COST: $990.00 (made in two installments; $550.00 and $440.00)

Client's Name *

First

Last

Is the person registering a new client? *

Client's Date of Birth (Month/Day/Year) *//

Please select the appropriate age of the client: *

Child (0-17 years of age)
Adult (18+ years of age)

Client's Gender *

Male
Female
Other

Preferred Pronouns *

She/Her
He/Him
Other

Preferred Pronouns (Please specify): *

Primary Caregiver's Name *

First

Last

Secondary Caregiver's Name

First

Last

Primary Contact's Name *

First

Last

Secondary Contact's Name

First

Last

Primary Email Address *

Secondary Email Address

Primary Phone *

Secondary Phone

Would you like to update the client's address? *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

CLIENT INFORMATION

Client's Marital Status *

Single
Dating
Married
Separated
Divorced
Widowed

Does the client have any children? *

Client's Family Relationship *

Nuclear Family (Two parents raising 1+ children in the home)
Single Parent Family (One parent raising 1+ children on their own)
Blended Family (Combination of parents or children from previous relationships)
Grandparent Family (One or more grandparent raising 1+ children in the home)
Extended Family (Several generations of family living in the same home)

Does the client have any siblings? *

Please list the children's names, ages and genders (i.e. Name, Age, Gender) *

Client's first language: *

Other languages spoken in the home:

EDUCATION

Is the client currently attending school? *

Please indicate the school name and the client's current grade (i.e. School Name, Grade): *

Has the client received services at school? *

Please indicate which services the client may have received at school: *

Speech-Language Pathology
Occupational Therapy
Counseling
Physical Therapy
Other
None of the Above

Please indicate the service(s) provided if not listed above: *

Please indicate the client's highest education completed: *

Please indicate any certificates, diplomas, or degrees attained:

Is the client currently employed? *

Is the client currently driving? *

MEDICAL HISTORY

Has the client had any of the following health concerns: *

Adenoidectomy
Allergies
Breathing difficulties
Chicken Pox
CVA (Stroke)
Ear Infections
Ear Tubes
Flu
Encephalitis
Head Injury
High Fevers
Seizures
Meningitis
Sinusitis
Sleeping Difficulties
Tonsillectomy
Tonsillitis
Vision Problems
Serious Illness
Serious Injury
Other
None of the Above

Select all that apply

Please indicate the client's allergies: *

Please indicate any serious illness: *

Please indicate any serious injury: *

Please identify other health concerns not listed above: *

Has the client been seen by/referred to any of the following specialists: *

Speech-Language Pathologist
Occupational Therapist
Social Worker
Psychologist
Counselor
Audiologist
Psychiatrist
Physical Therapist
Otolaryngologist
Neurologist
Gastroenterologist
Ear Nose and Throat Specialist (ENT)
NONE OF THE ABOVE

Please choose all that apply.

Please indicate the reason for visit/referral to the above specialist(s): *

Physician and/or other Healthcare Professional(s) who have seen the client (Please include the year seen):

Doctor, Speech-Language Pathologist, Occupational Therapist, Physical Therapist, Dentist, Orthodontist, Registered Nurse, etc.

Does the client have any formal diagnoses (i.e. by a Family Doctor, Specialist, Therapist, etc,) *

Please list any diagnoses and the year diagnosed (i.e. Diagnosis, Year) *

Has the client been hospitalized in the last 5 years? *

Has the client undergone any surgeries in the past? *

Please indicate the type of surgery and the year it occurred: *

Does the client currently take any medications? *

Please indicate current medications: *

Has the client had their hearing tested? *

When was the hearing test? *

What were the results of the hearing test? *

Does the client wear glasses or hearing aids? *

Glasses
Hearing Aids
Glasses & Hearing Aids
None of the Above

Does the client use adaptive equipment or mobility aids? *

i.e. walker, wheelchair, AFO's, adaptive utensils, etc.

Select the adaptive equipment or mobility aid(s) used by the client:

AFO (Ankle Foot Orthosis)
Adaptive Utensils
Stair Lift
Scooter
Ramp
Cane
Walker
Wheelchair
Other

Please indicate other adaptive equipment or mobility aids not listed above: *

SPEECH, LANGUAGE & OCCUPATIONAL CONCERNS

SPEECH / VOICE: Difficulties with: *

Speech Sounds / Enunciation
Tongue Thrust / Position
Lisp
Stuttering
General Voice (nodules, hoarseness, overuse, etc.)
None of the Above

LANGUAGE / COMMUNICATION: Difficulties with: *

Interaction and Engagement
Using Expressive Language
Understanding Language (receptive language skills, basic concepts, directions, etc.)
None of the Above

SOCIAL LANGUAGE: Difficulties with: *

Social Skills
Making and Sustaining Friendships
Play Skills and Engagement with Others
Communication and Anxiety
None of the Above

OCCUPATIONS: Difficulties with: *

Difficulty calming when upset
Frequent tantrums
Poor attention span
Fussy eater
Difficulties with transitions
Difficulties with following family routines
Mouths objects
Seems to be ‘on the go’ (fidgets, wiggles, difficulty sitting still)
Seeks movement (spins, rocks, jumps more than others)
Dislikes hair washing
Avoids messy play or certain textures with their hands
Enjoys messy play
Sensitive to noises (e.g. cries, runs, covers ears)
Avoids wearing certain textures of clothing
Appears clumsy
Dislikes playground equipment
Other
NONE OF THE ABOVE

Are the speech/language difficulties experiences in all spoken languages *

In which language are the speech/language difficulties? *

Has the client ever had Speech Language Therapy or Occupational Therapy? *

Speech Language Therapy
Occupational Therapy
Speech Language Therapy & Occupational Therapy

Please provide the location and year(s) Speech Language Therapy was provided. *

Please provide the location and year(s) Occupational Therapy was provided. *

Please provide the location and year(s) both therapies were provided *

Do you have documentation (reports, treatment summaries, goals, etc.) from previous therapies? *

Does the child enjoy or avoid the company of other children? *

Generally Enjoys
Generally Avoids

Does the child make eye contact with others when speaking to or interacting with? *

Always
Frequently
Sometimes
Rarely
Never

Is the child aware of, or frustrated by any speech / language difficulties? Please explain. *

What are your concerns regarding communication? *

What are the child's strengths? *

What are the child's weaknesses? *

What are the child's interests? *

DEVELOPMENTAL MILESTONES

Please provide the approximate age in months the client achieved the following developmental milestones:

Sat alone (unassisted) *

Babbles *

Said first words *

Put two words together *

Spoke in short sentences *

Grasped a crayon or pencil *

Walked *

Toilet trained *

Tell us about the client! How could this group benefit them? *

How did you hear about us? *

Please share how you heard about us.

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All groups are offered as a block of lessons. Therapists prepare and purchase materials for these groups ahead of time based on registered group members. For these reasons, we offer our groups on a prepaid program basis, and group fees are non-refundable. *

I have read the above and acknowledge that group program fees are non refundable.

Name