Adult Aphasia Therapy Intake Form
Personal Information
Full Name
Date of Birth
Phone Number
Email
Address
Emergency Contact
Name
Relationship
Phone
Medical History
Diagnosis (type of aphasia, date diagnosed)
Cause of Aphasia (e.g., stroke, brain injury)
Other Medical Conditions
Current Medications
Vision and Hearing Status
Communication Abilities
Communication Strengths
Communication Challenges
Preferred Methods of Communication
Personal Goals
What are your goals for therapy?
Activities important to you
Additional Information
Support at home / caregivers
Other relevant information