Intake Form

Intake Form

Thank you for taking the time to complete this form. The information you provide helps us better understand your child and prepare for their evaluation and/or therapy sessions. Please answer as completely as possible. If you are unsure about an answer, feel free to leave it blank or type "Unsure."
Child's Full Name

First NameLast Name
Nickname
Gender
Child's Date of Birth

MonthDayYear
Date
Is the child...
Parent/Guardian Name

First NameLast Name
Relationship to Child
Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Parent/Guardian Name

First NameLast Name
Relationship to Child
Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Child's Primary Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Child's Current School/Daycare
Primary reason for seeking speech therapy / Main concerns
Has your child ever received a previous speech, language, or hearing evaluation?
If yes, please provide details (date, provider, findings)
Does your child currently receive any other type of therapy?

Other
Child's preferred language:
List other languages spoken at home.
Do any of the following apply?
If "other", please explain:
Does the child:
Any family history of speech, language, or hearing difficulties?
If yes, please explain:
List family member's relationship to child and difficulty.
Relevant medical history (e.g., birth complications, illnesses, surgeries, hearing issues)
Additional comments or information you would like to share
How much of your child's speech do you understand?
How much of your child's speech do those less familiar with the child understand?
Who may we thank for this referral?
Should be Empty: