Intake Form

Please fill out the form below. Intake form must be submitted prior to evaluation/therapy session.

Client Name

First Name

Last Name

Date of Birth

YYYY

Caregiver's Name

First Name

Last Name

Primary email (Caregiver if client is a minor)

Phone

(###)

###

####

Primary mailing address:

Private Insurance- Name of insurance carrier

IE: BCBS, Aetna, Cigna, United, Etc. If private pay, please state "PRIVATE PAY"

Primary Insurance Card- MEMBER ID

Please provide the member ID of the insurance policy if using private insurance

Insurance Group Number

If PRIVATE PAY, please write "N/A/"

Client's Primary Care Physician (PCP)

Primary language(s) spoken in the home

Reason for Referral

Previous Therapy History

Please list any previous speech therapy providers or additional speech therapy services (i.e. school/Early Intervention)

Pregnancy and Birth History

Please provide any relevant birth or pregnancy history as known. Please provide birthweight and any reported complications.

Significant Medical History

Please provide any relevant medical history below.

Current Medications?

Additional Information

Please write any additional information that will be helpful for understanding the current concern.