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About Us
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Clinical Forms
Book your consultation
Contact
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Adult Intake Form
Today's Date
Client Name
Nickname
Date Of Birth
Age
Gender
Male
Female
Diagnosis (If Known)
City , State , Zip
Phone #1
Cell
Home
Work
Other
Phone #2
Cell
Home
Work
Other
Email #1
Email #2
Marital Status
Single
Married
Divorced
Widowed
If Under 18 , Name Of Parent/Guardian
Name Of Spouse or Close Realtive
Permission Of Contact
Yes
No
Contact Information
Others Living In the Home
Are you receiving any assistance in the home?
Yes
No
Describe
Language(s) Spoken
Are You Currently Driving?
Yes
No
Client’s Physician
Physician Phone Number
Physician Address
Other Physicians / Specialists Involved In Care
Referring Physician
Phone Number
Physician Address
Secondary Physician
Secondary Physician Number
Secondary Physician Address
Occupation
Employed
Retired
Unemployed
How did you hear about us?
Current Status
Please describe your present issue
Is your communication difficulty related to your Work?
Yes
No
Is your communication difficulty related to your Accident?
Yes
No
Date of Occurence
Describe
Briefly describe why you’re seeking an evaluation by a speech-language pathologist at this time
What do you think caused your speech problem?
What are you expecting out of this evaluation / meeting?
Have you ever had a previous speech, language or feeding evaluation / treatment?
Yes
No
By Whom
When
Describe the results
Are you currently working with another provider?
Yes
No
Provider Name
Contact Information
Location
Has the problem improved or gotten worse? Describe
When did you first notice the problem?
How does your communication difficulties impact your life, social, work, hobbies, etc.?
What strategies do you use to help cope with this problem?
Does anyone in your family have a history of the same (or different) communication difficulty?
Background & History
Describe any pertinent information regarding your medical history (birth injuries, abnormalities, surgeries, diagnoses, etc.) as well as when they were diagnosed and by whom
Describe your current health status:
Have you ever had surgery for a related issue?
Yes
No
Please Describe
Have you ever been hospitalized for a related issue?
Yes
No
Please Describe
Have you ever been in a serious accident?
Yes
No
Please Describe
Do you have a chronic illness? If so, please describe
Are you currently on any medications? If so, please list medication name and reason for medication
Medication 1
Medication 2
Medication 3
Medication 4
Do you have any physical disabilities?
Do you currently use any equipment? (communication device, walker, etc.) Describe
Check and describe all that apply
Allergies
Asthma
Attention Deficit Disorder
Auto accident
Brain injury
Breathing problems
Cancer
Cardiac issues
Cleft palate
Cognitive issues
Degenerative illness
Depression
Developmental delay
Diabetes
Ear infections
Encephalitis
G-tube
Hearing loss
Pneumonia
Psychiatric issues
Respiratory problems
Seizures
Stroke / TIA
Swallowing problems
Other
Describe:
Have you ever been evaluated by the following specialties? Check all that apply
Audiologist
Gastroenterologist
Occupational Therapist
Otolaryngologist
Physical Therapist
Psychologist
Psychiatrist
Speech Therapist
If yes, please describe the nature of the evaluation and any results
Highest grade completed
Degree earned
Name of Institution(s)
During school, did you have any problems with the following? Check all that apply
Learning
Understanding
Memory
Behavior
Attention
Reading
Speaking
Writing
Problem Solving
Are there any questions you would like us to answer for you?
Is there anything else that is important for us to know about you?
Person filling out the form
Relationship to the client
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