Oxford Speech Plus

At Oxford Speech Plus, we match our clients with team members who are the best fit for your family based on the needs and the clinicians’ area of expertise, skill and training. In order to direct your referral, please complete this questionnaire below and we will contact you when a clinician is available for an assessment.

Area of Practice

Name of the person making the assessment request *

First Name

Last Name

Phone number of person making the request

(###)

###

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Email *

Name of the person who the referral is for

First Name

Last Name

Age

Oxford Speech Plus Location:

Concerns/Additional Information

Please check off any of the areas listed below that capture your concerns:

uses minimal words

has difficulty understanding

has trouble making sounds

is not understood by others

has trouble interacting with others

stutters

makes errors with grammar

doesn’t know letter sounds

has difficulty with reading

has difficulty with writing

trouble saying longer words

makes sounds that are slushy

uses a hoarse voice quality

has difficulty with focus

difficulty managing emotions

Please list any medical diagnoses that have been given:

Please indicate why you would like to have an assessment at Oxford Speech Plus:

Please check off any of the areas listed below that apply as it relates to the person that this referral is for:

tongue tie was released at birth

tongue tie is currently present

had difficulty with breastfeeding as an infant

did not babble as a baby

thumb/finger sucking or long term pacifier user

is a restless sleeper and/or wakes often

sleeps with mouth open

did not pass infant hearing test

has had repeated ear infections

is a picky eater (avoids certain foods)

Availability

Please note what time you'd be available for ongoing sessions. Select all that apply.

Daytime

Evenings

First Available Time

Thank you!

Tillsonburg, ON

224262 Ostrander Rd
Tillsonburg, ON, N4G 4H1

Woodstock, ON

65 Springbank Ave. Unit 5
Woodstock, ON

Ingersoll, ON

90 Samnah Crescent,
Ingersoll, ON

Contact Us

226-325-7587
info@oxfordspeechplus.ca

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