INITIAL EVALUATION INTAKE FORM
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Feel free to call with any questions you might have or if you prefer to answer these questions over the phone.
(215)-645-2699 or contact@fairmountspeech.com
Email address *
Today's date *
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PERSONAL INFORMATION
Client first and last name *
Client or caregiver contact Information (phone number, email) *
Address (street, city, state, zip)
Date of birth *
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Emergency Contact Information (name, phone number) *
Language(s) spoken
Primary physician (name, phone number, address)
Referring physician (name, phone number, address) *
Other Physicians/Specialists involved in care
CURRENT MEDICAL STATUS
Diagnosis (if known)
Please describe your present issue *
When did it start? *
Has the problem stayed the same, improved or gotten worse? Please Describe. *
Are your deficits related to work or an accident? If yes, please explain and include date of injury.
Does anyone in your family have a history of the same (or different) difficulty?
What do you think caused your current deficits? *
Are you currently receiving assistance at home, work, school? *
Required
If yes, please describe the assistance needed.
Briefly describe why you are seeking an evaluation by a speech-language pathologist at this time *
What are you expecting out of the a speech therapy evaluation and treatment program? *
Have you ever had a previous speech, cognitive, language or swallowing evaluation/treatment? *
Required
If yes, please describe when, by whom, and what the findings were if any.
Are you currently working with another speech therapist? *
Required
Speech therapist name and contact information
How do your current difficulties impact your life, social, work, hobbies, etc.? *
What strategies do you use to help cope with this problem? *
MEDICAL HISTORY
Please describe your current health status *
Past medical history: Check all that apply *
Required
Please describe/include any information regarding your medical history (birth injuries, abnormalities, surgeries, chronic illnesses, accidents, diagnoses, etc.), when they were diagnosed and by whom *
Have you ever had surgery or been hospitalized for a related issue? *
Required
If yes, please describe related surgeries or hospitalizations
Are you currently on any medications? If so, please list medication name and reason for medication:
Do you currently use any equipment? (communication device, walker, glasses, dentures, hearing aids, etc.) If yes, please list them.
Have you ever been evaluated by the following specialties? Check all that apply *
Required
If yes, please describe the nature of the evaluation and any results:
SOCIAL HISTORY
Occupation (employed, unemployed, retired?) *
Are you currently driving? *
Required
Education: What is the highest grade you completed? *
Please list degree earned
Did you have difficulty with any of the following prior to your current deficits? *
Required
If yes, please describe difficulty prior to current deficits. *
What are your responsibilities in the home? Check all that apply: *
Required
Please list your hobbies, daily routine/schedule, interests *
Is there anything else that is important for us to know about you?
How did you hear about Fairmount Speech and Swallowing Therapy? *
Person filling out the form (include relationship to client)
What days and times work best for you and the client to attend weekly online therapy session? (Examples: evenings and weekends, Saturday and Sunday mornings, Wednesdays between 1 to 4pm)
Do you have a computer/laptop webcam, ipad, tablet to use for online therapy sessions?
Clear selection
Do you have Google Drive (or Gmail)?
Clear selection
Thank you for taking the time to fill out this form
Please reach out for any additional questions/information (215)-645-2699 or contact@fairmountspeech.com
I look forward to working with you!
A copy of your responses will be emailed to the address you provided.
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