Bilingual Speech-Language Assessment Intake Form
Client Information
Full Name
Date of Birth
Gender
Address
Phone Number
Email
Parent/Guardian Information
Name
Relationship to Client
Phone Number
Email
Referral Information
Referred By
Reason for Referral
Language Information
Primary Language Spoken at Home
Secondary Language(s)
At what age did the child start learning each language?
Describe how often each language is used (home, school, with friends, etc.)
Developmental & Medical History
Developmental History
Medical History
Hearing/Vision
Education & Services
Current School/Daycare
Grade/Level
Other services received (e.g., OT, PT, special education, counseling)
Speech-Language Concerns
Describe your concerns about speech, language, or communication
Do concerns exist in one or both languages? Please explain.
Additional Information
Is there anything else you would like us to know?