Holistic & Play-based Speech Therapy in your very own Kozy Corner. Lorem Ipsum is simply dummy text of the printing and typesetting industry. Lorem Ipsum has been the industry's standard dummy text ever since the 1500s, Get A Quote Call Us New Client Information Step 1 of 2 50% Child's Name: Date of Birth: MM slash DD slash YYYY School: Grade: Home Address: Weekly Schedule/ Availability: Child's Interests: Allergies: Parent Name: Phone:Email: Parent Name: Phone:Email: Emergency Contact:Pediatrician: Language(s) spoken in the home: Please answer the following questions to the best of your ability: Has your child been evaluated by any other professionals? (Physical therapy, ocupational therapy, ENT etc) Does your child have siblings? If so, do they receive services? Has your child had any ear infections? If so, how many? Does your child snore and/or sleep with mouth open? When was your child's hearing last tested? Did/ does your child suck their thumb or use a pacifier? If yes, how often? Please provide information about your child's birth history: (Type of delivery, Full-term/ premature, weight, complications)Did/ does your child breastfeed or bottle feed? Please list any difficulties you or your baby experienced during feeding. (difficulty latching, GERD, reflux, Mastitis etc)Please explain any concerns you have regarding your child's speech, language, feeding, or play skills:Please explain any concerns you have regarding your child's academic performance:
9:30 am - 6:30 pm - Mon - Fri
