Speech Therapy New Patient Intake Form
Patient Information
First Name
Last Name
Date of Birth
Gender
Male
Female
Other
Prefer not to say
Phone Number
Email
Home Address
Parent/Guardian Information (if patient is a child)
Parent/Guardian Name
Relationship
Phone Number
Email
Referral Information
How did you hear about us?
Referring Physician (if applicable)
Reason for Visit
Please describe the concern(s) regarding speech/language/hearing.
Medical History
Past or current medical conditions
Medications
Allergies
Developmental History (for children)
Significant birth or developmental history
Languages spoken at home
Previous therapy or interventions