Speech and Language Service Intake Form

Speech and Language Intake Form

Thank you for inquiring about our speech and language services. This information will help us better understand what your needs are for services and help guide our assessment process. After submission, our owner will reach out to discuss next steps.
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Child's Name

First NameMiddle NameLast Name
Child's Birth Date

MonthDayYear
Address

Street Address

Street Address Line 2

CityState

Zip Code
Home Phone

Area CodePhone Number
Child's Grade
Child's School Name
Parent/Guardian providing this information

First NameLast Name
Parent/Guardian Email
Parent/Guardian Contact Phone

Area CodePhone Number
How would you like us to contact you?
Choose one
If text messaging is chosen as primary contact, I understand and have been informed that standard text messaging (SMS) is not a secure form of communication and may carry risks to the privacy of my personal health information. These risks, including potential unauthorized access or disclosure, have been explained. The patient acknowledges understanding these risks and provides consent to communicate via SMS despite these limitations.
Who can we thank for the referral?
Why are you seeking a speech and/or language evaluation?

Hx of Therapy/Evaluations

Please be prepared to share copies of these evaluations
List any EDUCATIONAL treatment and/or evaluations including examiner, date, place, and findings
List any NEUROLOGICAL treatment and/or evaluations including examiner, date, place and findings
List any PSYCHOLOGICAL treatment and/or evaluations including examiner, date, place, and findings
List any PHYSICAL THERAPY or OCCUPATIONAL THERAPY treatment and/or evaluations including examiner, date, place, and findings
Please list any SPEECH treatment and/or evaluations including examiner, date, place, and findings?
List any AUDIOLOGICAL or HEARING treatment and/or evaluations including examiner, date, place, and findings
Does your child receive ACADEMIC TUTORING services? If so please list name of tutor and where services take place? How often?

Developmental/Medical History
How many weeks gestation was your child born at and birth weight
Did you experience complications during pregnancy, labor, or delivery?
If yes, please describe
Ages of milestones (sit, crawl, walk, speak first words, combine words)
Hx of vision or hearing concerns including PE tubes- if none type N/A
Hx of accidents or hospitalizations- if none type N/A
List hx of feeding difficulties (motor, sensory based or both)- if none type N/A
List current medications- if none type N/A
List current allergies- if none type N/A

Social-Emotional/Behavioral
Emotional Regulation: How does your child typically respond when they feel frustrated, upset, or overwhelmed? (e.g., shuts down, cries, gets angry, seeks help, wants physical comfort, etc.)
Peer Relationships: How does your child interact with other children (e.g., making friends, joining play, handling disagreements)?
Flexibility & Transitions: How does your child handle changes in routine, transitions, or unexpected situations?
Communication of Feelings: How does your child express their thoughts, needs, and emotions to others when big feelings occur? (e.g. can use emotion vocabulary, can state cause of feeling, can problem solve with you, needs a calm down period before talking, etc). Please describe.
Self-Awareness & Confidence: How would you describe your child’s confidence and ability to recognize their own strengths and challenges?

Speech and Language Development
Receptive Language (understanding): How well does your child grasp new vocabulary and concepts, follow directions (simple or complex), and understand less concrete language (inferencing/predicting, figurative language)? Please describe.
Reading Comprehension: How well does your child comprehend what they have read (e.g. can identify main idea, details, beginning, middle, end, author's purpose, themes, etc). Please describe or mark N/A if you child is not yet reading.
Expressive Language (verbal output): How does your child typically communicate their wants, needs, and ideas (e.g., single words, phrases, full sentences, gestures such as pointing, pulling you to an object they want, or repeating words/phrases you use). If using sentences are they grammatically correct? Please describe.
Expressive Organization: How well does your child verbally organize their thoughts when speaking (e.g., telling stories with details from start to finish, explaining the steps of how to do something, recalling vocabulary correctly- may use nonspecific words like "thing" or substitute words)? Please describe or mark N/A if your child is not yet speaking in complete sentences.
Written Expression: How well does your child express their ideas in writing? (Can they write single sentences, paragraphs, use correct grammar, punctuation, etc). Please describe or mark N/A if your child is not yet writing.
Pragmatic Language (social communication): How well does your child interact during conversations (e.g. beginning/ending conversations, sharing turns talking, staying on topic, joining conversations already in progress, changing topics smoothly, asking/answering questions, understanding social cues such as body language/tone of voice)? Please describe or mark N/A if your child is not yet using some form of language (verbal/AAC).
Functional Communication Across Settings: Are there differences in how your child communicates at home, at school, or with peers? For example, they might make requests at home but don't feel comfortable advocating for their needs at school or with peers. Please describe.
Is your child's speech understandable to you and unfamiliar listeners. If not, what sounds seem difficult for your child to pronounce and are there any other concerns (e.g. drooling, tongue thrust, speaks rapidly, speech sounds slurred or slushy)?
Does your child stutter and if so, would you characterize it as mild, moderate, or severe? If so, please describe or mark N/A if this does not apply.
Are you concerned about your child's vocal quality or resonance? If so, please describe or mark N/A if this does not apply.

Therapeutic Goals

We are in this together! Let us know what areas you feel are most important to you child's success.
What are 2-3 main goals you want to see your child accomplish as a result of therapy?
Any Additional Information We Should Know....
Client Agreements & Consents

1. Consent for Evaluation and/or Treatment
I voluntarily authorize S.O.A.R. Beyond Neurodiverse Therapy to provide speech-language evaluation and/or treatment services for my child. I understand that services will be individualized based on my child's needs and may include parent education, consultation with other professionals (with my written permission), and recommendations for home practice.
2. HIPAA Acknowledgment: Notice of Privacy Practices
I acknowledge that I have received or have had the opportunity to review the Notice of Privacy Policy describing how my child's protected health information may be used and disclosed.
3. Payment Policy
S.O.A.R. Beyond Neurodiverse Therapy is a private-pay practice.

Payment is due at the time services are rendered.

Accepted forms of payment include:

-Cash
-Check
-Electronic payment through Ivy Pay (HIPPA compliant mobile app)
If you choose to pay electronically through Ivy Pay, a valid credit card will be securely collected and kept on file. Your card will be charged on the day of your scheduled appointment.

S.O.A.R. Beyond Neurodiverse Therapy does not bill insurance. A superbill can be provided upon request for you to submit to your insurance carrier for possible out-of-network reimbursement.
4. Attendance & Cancellation Policy
Consistent attendance is essential for meaningful progress.

Please provide at least 24 hours' notice if you need to cancel or reschedule an appointment.

Appointments canceled with less than 24 hours' notice and no-show appointments may be charged the full session fee.

Repeated cancellations or missed appointments may result in the loss of your reserved therapy time or discharge from services.
5. Teletherapy Consent (only if applicable)
I understand that teletherapy services are delivered using a secure, HIPAA-compliant platform. I acknowledge the potential limitations of technology and agree to provide an appropriate environment for my child to participate safely.
6. Communication
I understand that routine communication may occur by phone or secure email. Text messaging may be used for scheduling purposes only. I understand that email and text messaging should not be used for emergencies.
Acknowledgements
I acknowledge that I have read and understand each of the documents and policies presented above, including the Consent for Evaluation and/or Treatment, Notice of Privacy Practices, Payment Policy, Attendance and Cancellation Policy, Communication Policy, Teletherapy Consent (when applicable), and the S.O.A.R. Beyond Neurodiverse Therapy Policies & Procedures. I agree to the terms outlined in these documents.
Name

First NameLast Name
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDateHourMinutesAM/PM Option
S.O.A.R. Beyond Neurodiverse Therapy

Policies and Procedures Manual available for download
Should be Empty:

Speech and Language Intake Form

Hx of Therapy/Evaluations

Developmental/Medical History

Social-Emotional/Behavioral

Speech and Language Development

Attention: Executive Functions

Therapeutic Goals

Client Agreements & Consents

Acknowledgements

S.O.A.R. Beyond Neurodiverse Therapy