New Client Intake Form

Please carefully review Our Policies before completing the form. If you have any questions, please feel free to contact our office. 

Client Name *
Client Name
Date of Birth *
Date of Birth
Sex *
Parent(s)/Guardian(s) *
Parent(s)/Guardian(s)
Address *
Address
Phone Number *
Phone Number
Emergency Contact Name *
Emergency Contact Name
Emergency Contact Phone *
Emergency Contact Phone
Client's Physician *
Client's Physician
Physician Phone Number *
Physician Phone Number
Physician Address *
Physician Address
Referring Physician
Referring Physician
Referring Physician Phone Number
Referring Physician Phone Number
Referring Physician Address
Referring Physician Address
Secondary Physician
Secondary Physician
Secondary Physician Phone Number
Secondary Physician Phone Number
Secondary Physician Address
Secondary Physician Address
Parent 1 Name *
Parent 1 Name
Parent 2 Name
Parent 2 Name
Marital Status *
What adults does the child live with? Check all that apply. *
Does the child have siblings, or are there other siblings in the home? *
Has the child had a previous speech, language or feeding evaluation / treatment? *
When?
When?
Were there any infections or illnesses during the mother's pregnancy? *
Was there any stress during the pregnancy? *
Were there any complications during labor or delivery? *
How was the child delivered? *
Check all that apply. Select "None" if none apply. *
Is the child up to date with immunizations? *
Has the child ever had surgery? *
Has the child ever been hospitalized? *
Has the child ever been in a serious accident? *
Does the child have a chronic illness? *
Is the child currently on any medications? If so, please list medication name and reason for medication. *
Medication List:
Does the child have any known allergies? *
Does the child currently use any equipment? (communication device, walker, etc.) *
Does the child have a history of ear infections, tubes, etc. or use hearing aids? *
Does the child have any known hearing loss? *
Is the child currently receiving any of the following services? *
Does the child do any of the following? *
If under 4 years of age, how many words does the child say?
If under 4 years of age, does the child produce sentences of the following length?
Does the child have any difficulty with the following? *
Has the child experienced any difficulty with feeding or swallowing? *
Is the child currently enrolled in daycare/ school? *
Does the child become easily frustrated with certain activities? *
Person filling out this form. *
Person filling out this form.