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Enrolment for new groups

CHILD INFORMATION (0–3 YEARS)

  1. REASON FOR CONSULTATION

What prompted you to schedule a speech and language therapy / neurologopedic consultation for your child?

  1. PREGNANCY AND BIRTH HISTORY

Was your child born prematurely?
Tak
No
Were there any complications during pregnancy or delivery?
No
Tak
Did your child require hospitalization or admission to a neonatal intensive care unit (NICU) after birth?
Yes
No

  1. FEEDING AND EATING

Did your child experience difficulties with breastfeeding or bottle-feeding during infancy?
Yes
No
Did your child experience choking during feeding?
Yes
No
Does your child currently experience difficulties while eating?
Yes
No
Does your child accept only certain foods or food textures? (food selectivity)
Yes
No
Can your child independently bite and chew foods that require chewing?
Tak
No

  1. COMMUNICATION AND LANGUAGE DEVELOPMENT

Does your child respond to their name?
Yes
No
Does your child point to objects or people of interest?
Yes
No
Does your child point to objects or people of interest?
Yes
No
Does your child use words meaningfully (e.g. mama, daddy, more, give, yum-yum)?
Tak
No
Does your child combine two words into simple phrases (e.g. give me, car goes, all gone)?
Tak
No
Does your child understand simple instructions (e.g. give it to me; come here; bring it to me)?
Tak
No

  1. OROFACIAL FUNCTIONS

Does your child often breathe through their mouth?
Yes
No
Does your child usually breathe through their nose?
Yes
No
Does your child sleep with their mouth open?
Yes
No
Does your child drool excessively?
Yes
No
Does your child currently use a pacifier/dummy?
Yes
No
Does your child drink from a bottle with a nipple/teat?
Yes
No

  1. HEALTH INFORMATION

Has your child undergone a hearing assessment other than the newborn hearing screening?
Yes
No
Is your child currently under the care of any healthcare or therapy specialists?
No
Yes

  1. DODATKOWE INFORMACJE

MEDICAL DOCUMENTATION

Please note that completing the form does not constitute a reservation of a place in the group. After submitting the form, please wait to be contacted by us in order to arrange an assessment meeting for the group.

Current prices for SST and ART sessions can be found in our price list.

A description of the sessions and further details can be found in the following sections:

— SST for children.

— SST for adolescents.

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