Speech Intake Form

Speech Intake Form
Are you 18 years or older and legally able to make your own decisions, or are you a parent/legal guardian completing this form for a minor or someone under guardianship?*

Yes, I am 18 or older and can legally make my own decisions.No, I am completing this form as a parent/legal guardian for a minor or someone under guardianship.
Before we can schedule your appointment, you'll need to complete our intake paperwork. Once you finish this screening form, we'll send the documents to you. How would you prefer to receive your intake forms?*

Text Message (SMS)Email
Primary Language*

EnglishSpanishOther

If applicable, please upload the legal paperwork establishing custody or guardianship (e.g., custody order, DSS paperwork, guardianship documents).

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Upload the front of the secondary insurance card covering the client.*

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Upload the back of the primary insurance card covering the client.*

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Speech Language History
Why are you seeking speech therapy treatment*
If speech therapy services are recommended, what days/times is the patient available for treatment? *
Questions and/or Requested Provider

*By submitting this document, you are indicating that the information you have provided above is truthful. Upon submission you will be redirected to our intake packet. All forms must be completed prior to moving forward with potential services.
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Speech Language History