WEST COAST SPEECH LANGUAGE PATHOLOGY LTD
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- Britney Violet Crawford
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1 WEST COAST SPEECH LANGUAGE PATHOLOGY LTD CASE HISTORY INFORMATION The following case history information is collected to support a speech language assessment and subsequent speech language therapy. Name: Date of Birth: Home Address: Today s Date: Home Phone: Cell Phone: Father s Name: Mother s Name: Guardian s Name: Sibling s Names: Who referred your child? What is the reason for this referral? Please be specific about what your concerns are about your child s speech and language: Names of Physicians or other health care professionals who have seen your child (e.g. audiologist, psychologist, OT, PT, IDP, etc) Medical History:
2 Does your child have any health problems now? Does your child have a diagnosis? If yes, by whom? When? Have there been any serious illnesses or injuries? Is your child on medication now? If so, please describe: Has your child had his/her hearing assessed? If so, when? Where? Results of Hearing Assessment? Speech & Language History: Do you have any concerns about your child s speech or language skills? If so, please describe: What therapy has your child had to address these concerns: Has your child attended any group therapy? Is your child aware of or frustrated by the problem? Does your child want to come to therapy? What is the child s first language? Third? Are you currently using any strategies with your child? Second Language? Has your child ever had speech or language therapy? When? Where? If so, with who?
3 Social/Play History: Does your child enjoy or avoid the company of other children? What are your child s favorite interests? Does your child make eye contact with you when speaking or interacting? Name of school? Teacher s name: Grade Phone #: How is your child doing in school? Does your child receive any special services? Please provide any other information that you believe may be related to your child s speech and language and that would be helpful for us to know during therapy sessions:
4 WEST COAST SPEECH LANGUAGE PATHOLOGY LTD Consent for Service I,, give my consent for, speech language pathologist, to provide speech and language assessment, consultation and therapy to my child,. Consent to Obtain Information I,, give my consent to West Coast Speech Language Pathology LTD to collect information pertinent to my child s speech and language development from the following professionals: Consent to Release Information I,, give my consent to West Coast Speech Language Pathology LTD, to share/release information pertinent to my child s speech and language development to the following professionals: Signature of parent/guardian: Relationship to child: Date: West Coast Speech Language Pathology LTD complies with the Personal Information Protection Act and the administration of its policies and procedures.
5 CONTRACT FOR SPEECH LANGUAGE PATHOLOGY SERVICES This contract is between (the Parents/Guardians ) and West Coast Speech Language Pathology LTD, ( WCSLP ). In consideration of the mutual promises contained within this contract, the Parents/Guardians and WCSLP agree to the following: 1. The WCSLP will provide speech language pathology services to, the child of the Parents/Guardians (the Child ). These services are to include one or more of the following: (a) screening of speech and language skills; (b) assessment of speech and language skills; (c) intervention for speech and/or language disorders and/or delays; (d) preparation of screening, assessment, progress and discharge reports as requested; (e) participation in team meetings with family and other professionals as required; (f) consultation with the Parents/Guardians and others involved; (g) preparation and delivery of referrals to other professionals as deemed appropriate by the Parents/Guardians and the SLP; (h) selection and implementation of augmentative and alternative communication devices; and (i) preparation of home programs, as requested. 2. The rate charged by WCSLP to the Parents/Guardians for the above services will be $ an hour, or $ per 45 minutes or $70 per 30 minute session. 3. WCSLP will charge the Parents/Guardians for the preparation of written reports as per the fee schedule. Reports are written following an assessment and/or upon request. 4. Where an appointment for the delivery of the Services is canceled by the Parents/Guardians, they will pay the WCSLP: (a) $0.00 if the cancellation occurs more than 24 hours before the scheduled appointment; (b) 100% of the scheduled payment if the cancellation occurs less than 24 hours before the scheduled appointment. 5. Where the Child fails to attend a scheduled appointment and that appointment has not been previously canceled by the Parents/Guardians, they will pay WCSLP 100% of their scheduled payment. The parties have executed this Agreement in Vancouver, British Columbia on, 20. PARENT/GUARDIAN Address : Phone: Janine Baker, Director of WCSLP Ltd.
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