Pediatric Speech Therapy Intake Form
Child Information
Child's Name
Date of Birth
Gender
Female
Male
Other
Address
Parent/Guardian Information
Parent/Guardian Name
Phone Number
Email Address
Relationship to Child
Medical/Developmental History
Relevant Medical Conditions
Previous Diagnoses (if any)
Allergies
Current Medications
Speech & Language Information
What are your primary concerns about your child’s speech/language?
Age when first words appeared
Age when short sentences appeared
Languages Spoken at Home
Has your child’s hearing been tested?
Yes
No
Previous Speech Therapy/Interventions
Other Concerns or Notes