New Client Intake Form

Date

First NameMiddle InitialLast Name

(He/Him, She/Hers, They/them, etc)

Date

(Mom, Dad, Legal Guardian, Child, Caregiver, etc.)

Street Address

Street Address Line 2

CityState

Zip Code

Please enter a valid phone number.Format: (000) 000-0000.

Rows	Monday	Tuesday	Wednesday	Thursday
9:00 AM to 11 AM
11:00 AM to 1 PM
1:00 PM to 3 PM
3:00 PM to 5 PM

Vacation, Out of State, etc.

Individuals experiencing voice difficulties should make an appointment with an otolaryngologist (ENT) prior to the initiation of services.

Please enter a valid phone number.Format: (000) 000-0000.

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date

Rows	Family Members / Caregivers / POA	Check if Legal Guardian / POA	State the Relationship	Their phone number	Check if this person lives with the client
1
2
3
4
5

Please enter a valid phone number.Format: (000) 000-0000.

If you don't have a copy of the documents, please requested from your medical provider or speech therapist. You can email the forms to slpclinic@depaul.edu or fax it at 312-476-3339.

Rows	Name	Relationship to the Client	Age
1
2
3
4

* Montessori, General Education, Special Education, etc.

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Rows	Therapy	Date	Location
1
2
3
4

Our clinic will need the necessary reports before moving forward with the next steps. Please requested it from your medical provider or speech therapist. You can email the forms to slpclinic@depaul.edu or fax it at 312-476-3339.

i.e. receptive and expressive language (what a child understands and is able to express), Articulation (Speech Sounds), Fluency (stuttering), or pragmatic (social skills and language)

Rows	Yes	No
Expresses frustration when trying to communicate
Has difficulty pronouncing certain sounds
Has difficulty answering questions
Has difficulty following directions
Struggles to convey clear message when speaking, even if words are easy to understand
Gets stuck on or repeats words when talking
Has difficulty with his/her voice, vocal quality or breathing
Has a hard time making friends
Has difficulty understanding and following social rules

Rows	No	Yes	Please Comment/Explain if yes
Have you ever had concerns about your child’s hearing?
Does your child use any amplification or other devices to aid hearing?
Does your child have frequent ear infections?

Rows	No	Yes	Please Comment/Explain if yes
Have you ever had concerns about your child’s vision?
Does your child currently wear corrective lenses?

Rows	Current Concern	Past Concern	Never a Concern
Motor (e.g., crawling, sitting, walking, running, clumsiness)
Self-help (e.g., dressing, toileting)
Feeding (e.g., drooling, choking, sensitivity to textures)
Early play (e.g., using toys appropriately)

Rows	Age
Babble (sound combinations such as “bababa” or “gaga”)
Say first word
Jabber in nonsense sentences that sound like adult language
Begin to put words together (e.g, “Mommy play”, “want drink”)
Use complete sentences

Rows	Check if applies	Mild, Moderate, or Severe
Work
Participating in Daily Activities
Socialize
Sing

Rows	Check if applicable	Age	How many per day?	Per Week?
Cigarettes
Pipe
Cigar
Chewing Tabacco
Smoke Recreational Drugs

Rows	Check	Please explain
Behavioral
Medication
Dose

0 is Worst, 6 is Best

Rows	Check If It Applies:	Please explain
Telephone without headset
Telephone with headset
Telephone with speakerphone
Talking: one to one conversation
Talking in noisy settings
Talking to groups
Yelling or cheering
Whispering
Imitating Others
Throat clearing
Coughing
Phonation during exercising
Singing
Other

Rows	Check If It Applies:	Please explain
Smoke
Chemicals
Allergens
Temperature changes

Rows	Services Rendered	When?	Where?
1
2
3

New Client Intake Form

General Information

Family and Provider History

Child Developmental History

Birth/Health History

Other Developmental Concerns

Speech & Language Development

Health History

Voice Use History

Goals

Adult Health History & Skills

Communication Skills

Daily Living Skills