Client Information Profile

The information you provide will help the Speech-Language Pathologist gain a thorough understanding of your child and enable provision of the most appropriate service and management.


  • Identifying and Family Information

  • MM slash DD slash YYYY
  • 1. Parent/Guardian

  • 2. Parent/Guardian

  • Speech, Language, Learning and Hearing

  • Birth History

  • Medical History

  • Developmental History

  • Educational History

  • General Behavior

  • Additional Comments/ Other relevant information

  • This assists us connecting you with a clinician who can match your schedule. Please list your availability using the following format: (e.g., Monday: 9:00 to 12:00, Tuesday: all day, Wednesday: 3:30 to 6:00, or n/a if this day doesn't work for your schedule.)

  • Additional Comments about Availability: (if you don't have a consistent schedule, and need to go week by week, please indicate so and some possible options for availability)

  • MM slash DD slash YYYY