Thank You

For registering your interest in the Key Worker Model for your child who needs early intervention.

General Information

How old is your child? *

Below 2 years

2 - 3 years

3 - 4 years

General Information

In order to ensure your child would benefit from this model, please tell us more about your child: *

My Child is Delayed in Talking

My Child is Difficult to Understand

My Child Stutters/Stammers

My Child has Reading Difficulties

My child is delayed in talking

Is your child verbal? *

Yes

No

My child is delayed in talking

How long are my child’s sentences? *

Nonverbal

Single words

2 - 4 words

4+ words

My child is delayed in talking

Approx. how many words does my child have altogether *

< 10 words

10 - 50 words

50 - 100 words

> 100 words

My child is delayed in talking

What would be your preferred location for the sessions?

At home

At the Clinic

At Childcare

A hybrid (a mix of 2)

My child stutters/stammers

When did you first notice the stutter? *

< 1 month ago

Between 1 - 3 months ago

4+ months ago

Since they learnt how to speak

My child stutters/stammers

Is there anyone in the immediate or extended family who stutters? *

yes

no

My child is difficult to understand

Does your child have noticeable pronunciation errors on specific sounds/letters? *

Yes

No

My child is difficult to understand

How easy is it for others (strangers) to understand your child? *

Easy

Not easy

Very difficult

My child has reading difficulties

Is your child increasingly refusing to engage in reading and other literacy-related activities? *

Yes

No

General Information

Where do you reside? *

Inner West of Melbourne

Western Suburbs of Melbourne

General Information

Would you like to be supported in other ways to optimise your child’s communication? *

General Information

Comment: (please list any other concerns you have) *

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