Child Intake Form

Questions?

If you have additional questions please call:

Office Phone: (980) 228-9240

Client Information

First name

Last name

Date of birth

Parent or Guardian Information

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. Subscriber ID, Group 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 picture of your insurance card (front & back). | (If you're unable to upload it here, please email a picture of your insurance card to contact@empowerspeechtherapypllc.com or text it to 980-228-9240.)

Add file

Please upload a file

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

Medical History

Has you 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 your child taking (if any) and for what conditions? Include the dosage and amounts.

Does your 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.

If you have any documentation related to your child's prior speech-language history (e.g. Evaluation reports, IEP documentation, etc) that you would like to share, please UPLOAD it here. You can also EMAIL it to contact@empowerspeechtherapypllc.com

Add file

Please upload a file

Does your child exhibit behavioral difficulties? If so, please briefly describe their behaviors? (This is important so that we match your child with a therapist that can meet their needs)

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

Preferred date for Initial Evaluation Appointment

Preferred days of the week/times for appointments (We will try to accommodate your request, but may have limited availability)

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

Add another emergency contact

How did you hear about Empower Speech Therapy, PLLC?

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

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