Speech and Language Intake Form

This form is HIPPA compliant and encrypted so your information will be kept secure!

Speech and Language Therapy Intake Form

Child's Name

Child's DOB

Parent Email

When did your child say his/her first word?

Combine 2 or 3 words?

Does anyone in the house speak a language other than English?

What is your child's primary language?

Secondary Language?

Has your child had a hearing test?

Yes No

If yes, when?

Results?

Has your child suffered from frequent colds or ear infections?

Yes No

How many?

Any relevant medical history/hospitalizations?

Is your child receiving any other services?

Learning Support

Other Services (please describe)

Service

Provider

How often?

Service

Provider

How often?

Service

Provider

How often?

Service

Provider

How often?

Had your child had a speech/language evaluation in the past?

Yes No

If yes, when?

From who?

If yes to above, please provide the results

Has the child had a previous speech, language or feeding treatment?

Yes No

By whom?

Please describe the results

Does your child have an IEP?

Yes No

What services does your child receive at school through their IEP?

What are your concerns regarding speech/language issues?

Is there anything additional you would like to share about the family/home environment?

Evaluation

Briefly describe why you are seeking an evaluation by a speech-language pathologist at this time

At what age did you first notice the problem?

What are you expecting out of this evaluation/meeting?

How do the child's communication difficulties impact the family?

If anyone else in the family has a speech or language diagnosis, please describe

Is the child aware of or frustrated by their communication difficulties?

Diagnoses—List any known medical diagnoses or medical conditions and dates of diagnosis:

Family Information

Parent/Guardian

Phone

Parent/Guardian

Phone

Preferred Methods of Communication

Call

Text

Leave Message OK?

Sibling

Age

Therapy received (OT, PT, SLP, SW)

Sibling

Age

Therapy received (OT, PT, SLP, SW)

Sibling

Age

Therapy received (OT, PT, SLP, SW)

Sibling

Age

Therapy received (OT, PT, SLP, SW)

STRENGTHS & INTERESTS

What are your child's strengths?

What games, activities, characters, and/or toys does your child enjoy?

Do you have a family pet?

What are your favorite things to do as a family?

Areas of Concern/ Goals of Therapy

What are your primary concerns about your child?

Have you used any strategies or techniques at home to address these concerns? Please list.

What are your goals for speech therapy?

Is there anything else your SLP should know?:

Your information will be encrypted.

Speech and Language Intake Form

This form is HIPPA compliant and encrypted so your information will be kept secure!

Speech and Language Therapy Intake Form

Evaluation

Family Information

Areas of Concern/ Goals of Therapy

This form is HIPPA compliant and encrypted so your information will be kept secure!

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