Speech Therapy Intake Form
Thank you for inquiring about services with Uplift Therapies. Below are some general questions to help us understand your main concerns, as we look at setting up an evaluation. Thank you for your time to complete the following form. Please reach out with any question! 
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Your full name
Relationship to Client
Client's full name
Address (Including City, State)
Client's Date of Birth
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Gender
Insurance Provider (Or clarify if seeking Private Pay options)
Please list day and time options that work best for you and your child for an initial evaluation. 
Are you interested in-office or teletherapy visits? 
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In your own words, how would you describe your current concerns for your child's communiation?
If your child is in school, are there any concerns about academic performance (like reading, writing, or any subject area?)
Does your child have any sensory seeking behaviors or sensory avoiding behaviors (i.e., avoiding certain sounds, difficulty sitting still, difficulties with transitions or emotional outbursts?
Is your child seeing any other specialty doctors or therapists? 
Do you have any concerns related to feeding skills or swallowing safety? 
What are some of your child's favorite toys/interests?
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