Enquiry form

If you feel Christopher Place can help your child, please complete this form.
Note that all questions marked with a * are compulsory.

Name of Parent(s)*
Address*
Tel No*
Email address*
Name of child*
Child's date of birth*

Male Female

Sex:*

How did you first hear about the centre
What are your specific concerns about your child?*
Do you have any other concerns about their development?*
Please give an example of what they understand*
Please give an example of how they express themselves*
How do they like to play?*
How does he/she relate to other children?*

Has your child been seen by other professsional?

Occupational Therapist
CDC Team
Speech and Language Therapist
Paediatrician
Psychologist
Audiologist
GP
Other
If other please provide information
Does your child attend a nursery/playgroup/school?*
Have they raised any concerns?
How are you hoping that the Centre could help you and your child?*
Any other comments?