*Required Fields *Do you consent to a virtual appointment? YesNo If your child is eligible for services, the SLP will provide more details regarding the virtual appointment. *How did you hear about us? —Please choose an option—Check it Out ClinicChildcareChildren's Aid SocietyDoctorFriendInfant HearingOther ProfessionalPediatricianSchoolSibling at Early WordsOtherOntario Early Years Centres(OEYC)Parent Family Literacy Centre *Does the child live in the Hamilton Area? YesNo The Hamilton Area includes: Ancaster, Binbrook, Carlisle, Carluke, Copetown, Dundas, Elfrida, Flamborough Centre and West, Freelton, Greensville, Hamilton, Hannon, Jerseyville, Lynden, Millgrove, Mount Hope, Mountsberg, Rockton, Sheffield, Stoney Creek, Strabane, Tapleytown, Troy, Waterdown, Westover, Winona, and Woodburn. *Is the child on a waitlist or receiving services anywhere else? (e.g. McMaster Children's Hospital, Chedoke Hospital, Contact Hamilton, Ron Joyce Children's Health Centre, Developmental Pediatrics at Chedoke, The Hospital for Sick Children, ErinOak Kids, Lansdowne Children's Centre, etc.) YesNo If Yes, where And for what services: Please note: If you are concerned that your child has other developmental challenges in addition to speech and language needs, please contact: Developmental Pediatrics and Rehabilitation - Intake Department 905-521-2100 ext. 77950 (Located at the Ron Joyce Children’s Health Centre, McMaster Children’s Hospital) Additional information on services and a copy of the referral form can be found on their website. Click Here *Please describe the reason for your child's referral to Early Words. (e.g., Why are you concerned about your child's speech and/or language development? Who suggested that you contact us and why?) *Your First and Last Name *What is your relationship to the child __________________________________________________________________ *Child's First and Last Name *Child's Date of Birth. Please use the format YYYY-MM-DD. For example, the birthday of January 31st, 2012 would be written as 2012-01-31. *Gender MaleFemaleOther *Health Card Number __________________________________________________________________ *Your Full MAILING Address. Please be sure to include the street address, the apartment or unit numbers, the city and the postal code. *Phone Numbers ext.homeworkcell ext. —Please choose an option—homeworkcell br> ext. —Please choose an option—homeworkcell *Your Email __________________________________________________________________ *Was the child a full term baby? YesNo, please describe Was the child followed by Neo-Natal Clinic at McMaster Children's Hospital (formerly known as the Growth & Development Clinic)? YesNo *What age did the child start walking? *Does the child play well with other children? YesNo, please describe *Are there any other Health Concerns about this child? NoYes, please describe Are there any Specialists Involved in the child's care? Other than speech and/or language skills, do you have any concerns about how the child is growing or developing? NoIf Yes, please describe *Has anyone mentioned any concerns about the child's growth or development? NoIf Yes, please describe Does your child respond when you call his/her name? (i.e. by turning to look at you, or stopping what they are doing) YesNo Does your child take your hand and pull you to something he/she wants? (i.e. to the fridge to get a drink) YesNo Does your child have any characteristics or play behaviours that are unique or that you are concerned about? (i.e. Lines up toys, no eye contact, spins wheels rather than driving the car) YesNo Have any possible diagnoses been suggested? NoYes, please describe __________________________________________________________________ Family Information Language(s) Spoken at Home Name of person(s) who have legal decision-making rights for this child: *Your Marital Status MarriedCommon-LawNever Married or Never Common-LawSeparatedDivorcedWidowed Is there a legal custody arrangement? NoYes If yes, please describe the arrangement. JointSole MotherSole Father If the custody arrangement is solely with one parent, does the other parent have access? YesNo Please describe any other information that you feel Early Words should know about the child's legal custody arrangement. __________________________________________________________________ Parent/Guardian 1 Relationship to child First and Last Name Full Mailing Address if different than above Please be sure to include street address, apartment or unit numbers, city and postal code Phone ext. —Please choose an option—homeworkcell Occupation __________________________________________________________________ Parent/Guardian 2 Relationship to child First and Last Name Full Mailing Address if different than above Please be sure to include street address, apartment or unit numbers, city and postal code Phone ext. —Please choose an option—homeworkcell Occupation __________________________________________________________________ Parent/Guardian 3 Relationship to child First and Last Name Full Mailing Address if different than above Please be sure to include street address, apartment or unit numbers, city and postal code Phone ext. —Please choose an option—homeworkcell Occupation __________________________________________________________________ Children's Aid Involvement Children's Aid SocietyCatholic Children's Aid Society Worker Name Phone ext. homeworkcell __________________________________________________________________ Who else lives in the home? In relation to the child Name Age BrotherSisterGrandparentAuntUncleFriendBorderOther if other, please describe ------------------------------------------------------------------ In relation to the child Name Age BrotherSisterGrandparentAuntUncleFriendBorderOther if other, please describe ------------------------------------------------------------------ In relation to the child Name Age BrotherSisterGrandparentAuntUncleFriendBorderOther if Other, please describe ------------------------------------------------------------------ In relation to the child Name Age BrotherSisterGrandparentAuntUncleFriendBorderOther if Other, please describe __________________________________________________________________ School and Child Care Experiences *Does your child attend Childcare or Preschool Yes, please fill in belowNo Name of Child Care Days Attending Centre-based care? YesNo, please describe the type of care Resource Teacher Involved? YesNo Name of Resource Teacher ___________________________________________________________________ SCHOOL *Please select the Grade your child will be entering in the next calendar September. NEXT Grade Level your child will enter the following SeptemberNot EligibleJunior KindergartenSenior KindergartenGrade 1Eligible-Not AttendingUndecided Name of School Days Attending Resource Teacher Involved? YesNo Name of Resource Teacher ____________________________________________________________________ Doctor Information *Family Doctor's Name City *Can we send a letter to your child's family doctor to let them know a referral to Early Words has been made?YesNo Are there any other professionals involved with your child? YesNo Would you like them to receive a letter to confirm a referral to Early Words? Name City Consent?YesNo Name City Consent?YesNo ____________________________________________________________________ HEARING *Do you have any concerns about your child's hearing skills?NoYes, please describe