Intake Form

New Client Intake
Please complete this confidential intake form prior to your first appointment. Information is collected in accordance with provincial privacy legislation (BC PIPA, Alberta HIPA/PIPA, Saskatchewan HIPA).
Client Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Best email contact:
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
- Primary Diagnosis (e.g ALS, Parkinson's, Stroke, other named)
- Date of Diagnosis
  
  MonthDayYear
  Date
- Other relevant medical history:
- Neurologist / Specialist Name:
- Primary Physician Name:
- Medications (can be discussed at a later date if you do not have them available)
- COMMUNICATION
- Slurred speechStutterReduced loudnessVoice strainFatigue when speakingWord-finding difficultyReduced verbal outputMemory concernsDifficulty expressing selfDifficulty understandingNo concerns currentlyOther
- When did these changes begin? Explain what you noticed.
- No supportsWritingText-to-speech appSpeech-generating device (AAC)Communication partner assistanceUsing picturesSimple communication boardOther
- What matters most right now regarding communication?
- Swallowing and Nutrition
- No concernsOccasional coughing/choking with foodCoughing with liquidsTrouble swallowing pillsFood sticking (in mouth or throat)Prolonged mealtimesAvoiding certain texturesWeight lossCurrently tube fedOther
- Have you had your swallow assessed previously by SLP or swallow x-ray (VFSS)?
- Regular solidsSofter solidsMinced / moistPureedThickened liquidsTube feedingUnsure
- BREATHING & COUGH
- No concernsShortness of breathFatigue / effort with speakingWeak coughMorning headachesSleep disruption
- NoneBIPAPCPAPCough AssistSuctionOxygen
- NoneIMST (inspiratory muscle strength training)EMST (expiratory muscle strength training)BothUnsure
- Respiratory Specialist involved? (e.g. Respiratory Therapist or Pulmonologist)
- Daily Function & Supports
- Lives alone at homeLives with spouse/partner/familyAssisted LivingLong term care
- Primary communication partner(s). Name person (if applicable)
- Working full-timeWorking part-timeOn leaveRetiredNot working
- What is your top priority for therapy at this time?
- Consent & Authorization
- I authorize Empower Speech Solutions to communicate with my physician(s)I authorize communication with my neurologist or specialty clinicI authorize communication with other healthcare providers involved in my care
- Additional providers (if applicable) - i.e. Homecare
- Client / Guardian Signature*
- Date Signed*
  
  MonthDayYear
  Date
Should be Empty:

New Client Intake

COMMUNICATION

Swallowing and Nutrition

BREATHING & COUGH

Daily Function & Supports

Consent & Authorization