Let’s Play - How can we help?

Your Child's Name *

First Name

Last Name

Date of Birth

MM

DD

YYYY

Parent/Carer Name

First Name

Last Name

Phone *

(###)

###

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What area/s does your child need support with? *

Please select all that apply

Speech/Articulation - difficulty pronouncing sounds, they are difficult to understand

Receptive Language - difficulty understanding instructions, answering questions etc.

Expressive Language - difficulty using spoken words, not putting words together in phrases/sentences, difficult expressing themselves

Friendship/Social Skills - support initiating interactions, understanding friendships, conversations, perspective taking, advocating and understanding their communication needs/differences

AAC or Multimodal Communication - supporting your child to communicate in other ways than verbal speech (Key Word Sign, Voice Output Devices, Communication books, Chat boards etc.)

Literacy - difficulty with reading or spelling

Fluency - stuttering, repeating sounds/words/phrases, gets stuck on words, dysfluency impacts their ability to get their message across

Voice - differences with voice quality (scratchy/rough), volume differences

Feeding or Oral Motor - fussy eater/food aversions, difficulty chewing or swallowing, excessive drooling