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Image of girl with crayon plus a quote "Our philosophy is to see your child as a 'whole' and maximize their ability to communicate."

 

Patient Survey

Patient's Name:
  
     
E-mail Address:
  
     
Favorite Foods:
  
     
Favorite Toys:
  
     
Favorite Games:
  
     
Favorite Songs:
  
     
Favorite Stories or Books:
  
     
Is your child on any food restrictions?
  
     
What words/ phrases/ sentences does your child use to communicate (tell you something, comment, call attention to something, ask for something)
  
     

 

 
 
 
 

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Children's Speech Care Center
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