Apraxia of Speech Intake Assessment Form
Client Information
Full Name
Date of Birth
Age
Gender
Female
Male
Other
Parent/Guardian Name (if applicable)
Referral Information
Referred By
Reason for Referral
Medical History
Relevant Medical Diagnoses
Medications
History of Hearing/Vision problems
Developmental History
Speech and Language Development
Motor Development
Communication Skills
Area
Description/Notes
Expressive Language
Receptive Language
Speech Sound Production
Intelligibility
Nonverbal Communication
Apraxia-Specific Observations
Inconsistent speech errors
Difficulty with imitation of sounds or words
Groping or searching behaviors
Prosody/Stress Errors
Other Observations & Notes
Assessment Results
Screening/Assessment Tools Used
Summary of Results
Recommendations
Assessor Name
Date of Assessment