Bridges Speech Center LLC

Demostration Therapy Add

Inquiry number

Name

Session Date

Date of birth

Dates of demonstration therapy

Parent: Mother (MSL)

Difficult Sensitive Concerned Unaware

Supportive Denial Demanding Impolite Language Barrier

Parent: Father (MSL)

Difficult Sensitive Concerned Unaware

Supportive Denial Demanding Impolite Language Barrier

Caregiver (MSL)

Difficult Sensitive Concerned Unaware

Supportive Denial Demanding Impolite Language Barrier

Whom communicate to: (MSL)

Mother Father Caregiver

Caregiver’s Name and relationship

Other information:

What approach is used?

Concerns of parent/patient*

Information received through parent/caregiver on client’s preference*

Client observation: Preferences, concerns noted, associated issues*

Information parallel therapist and supervisor to be aware of

Demonstration session report*: