Child Intake Form

Please provide as much information as you can. The questions marked with an asterisk (*) are required.

If you have additional questions please call:

Client Information

First name

Last name

Date of birth

First name

Last name

Relationship to child

Phone number

Home address

Email address

Name of child's primary care doctor

Primary care doctor's phone number

Name of Insurance Provider

Insurance policy details (e.g. Group ID, Subscriber ID, etc) & phone number for insurance carrier

Name of Primary Subscriber on Insurance Plan

Date of birth of Primary Subscriber on Insurance Plan

Please upload a photo of your insurance card (front & back of card)

Briefly describe why you're seeking a Speech- Language Pathologist at this time.

At what age did you first notice a problem with your child's communication abilities?

Has your child had any previous speech/language evaluation or treatment? If so, when and how long did your child receive services?

Is your child aware or frustrated by their communication difficulties?

Yes No Other

Has the child been treated by a doctor in the last 12 months?

Yes No

If yes, please describe the reason for the visit

Has your child's hearing been tested recently? If so, what were the results?

Does your child have a history of chronic ear infections?

Yes No

What medications is the child taking (if any) and for what conditions? Include the dosage and amounts.

Does the child have any allergies to medications or foods?

Is your child currently enrolled in school? If so, where do they attend school?

Does your child currently show any learning difficulties in school? If so, please describe their learning difficulties.

Please provide any other information that we should know, in order to better meet your child's needs.

How did you hear about Empower Speech Therapy, PLLC?

Google (or other web search) Doctor or Physician Family member, friend, etc. Other

Your information will be encrypted.