Autism Spectrum Speech Therapy Intake Form
Client Information
Full Name
Date of Birth
Gender
Address
Parent/Guardian Name
Phone Number
Email
Medical & Developmental History
Diagnosis (if any)
Other Therapies (current or previous)
Medications
Speech & Language Concerns
Describe your concerns regarding speech and language
Age of first words
Current communication methods
Languages spoken at home
Social & Behavioral Information
Strengths and Interests
Any Challenging Behaviors?
Goals for Therapy
What are your goals for speech therapy?
Additional Information
Is there anything else you would like us to know?