Articulation Disorder Therapy Intake Form
Client Information
Client Name
Date of Birth
Age
Parent/Guardian Name
Address
Phone Number
Email Address
Medical & Developmental History
Relevant Medical History
Comments on Early Developmental Milestones
Hearing/Vision Concerns
Speech & Language
Describe Speech Concerns
When Were the Difficulties First Noticed?
Previous Speech Therapy (if any)
Languages Spoken at Home
Family History of Speech/Language Difficulties
Additional Information
Other Concerns/Goals for Therapy
How Did You Hear About Us?
Date
Signature