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. After submission, our owner will reach out to discuss next steps.
Today's Date*

MonthDayYear
Date
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 - examiner, when, where and findings
List any NEUROLOGICAL treatment and/or evaluations - examiner, when, where and findings
List any PSYCHOLOGICAL treatment and/or evaluations - examiner, when, where and findings
List any PHYSICAL THERAPY or OCCUPATIONAL THERAPY treatment and/or evaluations - examiner, when, where and findings
Please list any SPEECH treatment and/or evaluations-examiner, when, where, and findings?
List any AUDIOLOGICAL or HEARING treatment and/or evaluations - examiner, when, where and findings
Does your child receive ACADEMIC TUTORING services? If so please list name of tutor and where services take place? How often?

Speech and Language Intake Form