Child Intake Form

Welcome to Empower Speech Therapy! We're so glad you're here. This secure form helps us learn more about your child and prepare for their upcoming evaluation, so we can provide the best support possible. Please take your time—there’s no rush or pressure. If you’re unsure about anything, just do your best. We’re here to make this process simple and supportive. If you have any questions, feel free to contact us anytime. The questions marked with an asterisk (*) are required.

Please correct the errors described below.

Client Information

Parent or Guardian Information

    Please upload a file

    Medical History

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      Emergency Contact Information (You must list someone other than yourself)

      Add another emergency contact

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