Speech Therapy Intake Form

"*" indicates required fields

Step 1 of 5

Child's Name*
Child's Date of Birth*

Parent Information

Parent Name*

Tell Us What Brought You Here

Which of your child's speech-language skill deficits led you to seek intervention from a speech-language pathologist?*
Check all that apply.
Do any other close family members have speech, language or related difficulties/disorders (i.e., autism, ADHD, dyslexia, etc.).*
Relation to child
For each additional relative with relevant diagnoses, click the "+" symbol to create another entry. If none, enter "None" in the first column/row.