New Patient Questionnaire

Please fill out this questionnaire so our specialists can help you in the best possible way.

Basic Info About Patient Concern & History Expectations

Your full name *

Phone number *

Email (optional)

Select branch

Preferred language

How did you hear about us?

Patient

Child (0–17 years)

Adult (18+ years)

Child's name

Date of birth

Gender

Boy Girl

Kindergarten / School

Are there other children in the family?

Yes No

Your age

Main concern / complaint *

Which areas are you concerned about? (select multiple)

Speech / language development Behavioral problems Learning difficulties Social communication Motor development Sensory sensitivity Emotional problems Sleep disorders Attention / concentration Other

Any previous diagnosis?

Have you had therapy before?

Yes No

Current medications

Which service are you interested in?

Speech Therapy Psychological Support Inclusive Education Sensory Integration Therapeutic Exercise & Massage Psycho-Pedagogical Support Occupational Therapy Mini Kindergarten Not sure — I want an assessment

Preferred time

Morning (09:00–12:00) Afternoon (12:00–15:00) Evening (15:00–18:00) Any time

Your expectations

Additional notes

I consent to my data being processed for treatment purposes

"Loqos" Psychological and Speech Center, established in 2014, provides services for all age groups.