Stuttering Evaluation Client Intake Form
Personal Information
Client Name
Date of Birth
Age
Gender
Male
Female
Other
Address
Phone Number
Email
Referral Information
Referred By
Reason for Referral
Stuttering History
Onset of Stuttering (age, circumstances, etc.)
Describe the stuttering pattern
Family history of stuttering
Previous speech therapy? (If yes, provide details)
Communication
Describe communication concerns
Impact of stuttering on daily life
Situations that worsen or improve stuttering
Medical & Developmental History
Medical conditions or medications
Developmental milestones (speech, motor, cognitive, social)
Additional Information
Other relevant information