Speech Therapy Patient Intake Form

Patient Information Full Name Date of Birth Address Phone Number Email

Parent/Guardian Information (if applicable) Parent/Guardian Name Parent/Guardian Phone Parent/Guardian Email

Referral Information How did you hear about us?

Reason for Referral Briefly describe the reason for seeking speech therapy

Medical History Relevant medical history, diagnoses, or conditions

Developmental History Were developmental milestones (e.g., talking, walking) met as expected?

Previous Therapy Has the patient received speech therapy before? If yes, where and when?

Additional Information Is there anything else you’d like us to know?