Speech Therapy Intake Form

Start with the patient's basic details.

Name *

DOB *

Sex *

M F

Address (Home) *

Address (Preferred for Therapies)

Add the main caregiver contact first. The second contact is optional.

Caregiver Name (Mother) *

Phone Number *

Caregiver Name (Father)

Phone Number

Email Address *

DX

These details help confirm admission and coordinate availability.

Caregiver provided verbal consent for admission and treatment *

Yes No

Address verified *

Yes No

Attends school *

Yes No

Preferred Available Days + Times *

Weekends are available if needed *

Yes No

Finish with language, service history, and medical notes.

Primary Language at Home *

Example: English or Spanish

Has the patient received services before?

Has the patient had any surgeries or injuries in the past 2 years?

List of medications / allergies

Speech Academy