Allied Health Services for Children

START Program

Support Team for Assessment Rehabilitation & Training

STARTSchool Registration Form

Teachers please complete this form & return to your PUF Coordinator or Fax to Kerry McKinnon at (403) 314-5230

Child’s Name:
Last name, First Name / Birthdate:
yyyy/Mon/dd / Parent(s) Name(s):
Home Address: / Home Phone:
ECS/School: / Phone: / Fax:
School Contact Person:
Tell us the name of the school staff we should contact for changes to appointment dates and times.
Address:
Billing Address (if different from above):
Therapy Location (if different from above):
Teacher: / Teaching Assistant:
Previous experience with a special needs child?Yes/No
Days and Times Child is in Attendance at School:
RequestedServices (Please indicate what services you would like SLP ______
and what frequency e.g 1/month, 4/year) OT ______

PT ______

* Please note - decisions regarding frequency are based on the child’s needs, funding and therapist availability.
Preferred Therapy Days and Time:
Would you like us to attend a case conference for this student? No Yes When ______
Please attach the school calendar with the dates of school holidays, teacher conventions and field trips:
Previous Assessments Completed: Speech-Language Pathology Occupational Therapy
Physical Therapy Psychology
Please provide the therapist’s name, agency, date of assessment and attach reports if available.
What are 1 – 2 questions you would like answered about this student and/or your concerns?

START Child Profile - To be completed by the parent, caregiver or legal guardian

Child’s Name: ______Alberta Personal Health #: ______

Last name, First Name

DOB : ______Physician:______

dd/Mon/yyy

1. Background Information (as applicable) Please include dates, test results and reports if available

Diagnosis:

Hospitalizations or Surgeries:

Significant illnesses or injuries:

History of Seizures:

Any Allergies?

History of Ear Infections?

Vision Testing:

Hearing Testing:

Medications (please list)

Family History (Are there any changes in the family situation that we should be aware of)?

Professionals, agencies or programs involved with your child to date. Please provide the therapist’s name, agency, a copy of any assessment reports if they are available, and describe the results, if appropriate.

Speech-Language PathologyOccupational Therapy

Physical Therapy Psychology

  1. Please tell us aboutyour child’s strengths or favourite activities.
  1. What are your greatest concerns about your child?

Page 2 START Child Profile Name of Child: ______DOB ______

Last name, first name yyyy/Mom/dd

4. Please complete the following checklist questions to assist us in identifying your child’s needs:

Communication:

My child’s speech is difficult to understand.

My child has difficulty forming sentences and expressing him/herself.

My child’s sentences sound immature.

My child has poor vocabulary skills.

My child repeats or prolongs sounds or words while speaking.

My child has difficulty understanding questions or commands.

Self Help Skills:

I have concerns about my child’s self-help skills (e.g. dressing, feeding, toileting). Please list :

My child dislikes certain foods. Please describe (ie. certain temperatures, textures or particular foods):

Social Skills:

My child has difficulty interacting with other children. Please describe:

Motor Development:

My child has difficulty holding a felt pen or crayon.

My child dislikes fine motor activities such as colouring, cutting and gluing.

I am concerned about my child’s eye-hand coordination.

My child has difficulty walking, running, or climbing stairs.

My child has difficulty maintaining balance.

My child’s ability to move and coordinate actions seems immature or unusual.

My child has difficulty throwing, catching, and/or kicking a ball.

I have concerns about my child’s physical strength, posture, flexibility, or muscle development. Please specify:

My child has (or may require) special equipment for sitting, standing, or walking. Please specify:

  1. What goals would you like to see your child achieve during the upcoming school year
  1. Please list any other agencies, professionals or programs your child may become involved with during the upcoming school year such as Children’s ServicesCenter – TAC program.
  1. Do you have any other information or concerns you wish to share with us about your child?

Please complete both pages of the Child Profile and return to the teacher.