New Client Quick Intake Sheet
Email address *
What is your child's name? *
Your answer
What is your child's current age? *
Your answer
What is your child's date of birth?
Your answer
What is your name? *
Your answer
What is your phone number? *
Your answer
What is your email address? *
Your answer
What services are you seeking?
What areas are you concerned about? (check all that apply) *
Required
Has your child had a speech/language evaluation? *
(0ptional) What evaluations has your child had? (speech/language, OT, PT, developmental, neuropsych, psychoeducational)What were the results?
Your answer
Has your child had any previous speech/language therapy? *
(Optional) Please share any pertinent information about your child's previous speech/language therapy?
Your answer
(Optional) Is there anything else you would like to add about your reason for seeking speech/language help?
Your answer
How many health insurance plans is your child covered under? *
Which insurance plans cover your child? *
Required
When would you like to get started? *
Please describe your child's general availability (days and times s/he could attend sessions on a regular basis). *
Your answer
How would you like to be contacted about next steps? *
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