SPEECH THERAPY INTAKE FORM
This intake form can be mailed to 119 Callibluff Drive, Summerville, SC 29486, faxed to
(843) 793-0298 or emailed to [email protected]
Child's Name: ________________________________ Child’s DOB: ____/____/______
Child’s Gender: MALE FEMALE
Child’s Social Security No.: _________________________
Parent/Guardian Name(s): ___________________________________________________________
Address: ___________________________________________________________________________
Cell Number: _________________ Email Address: ______________________________
Child’s School/Daycare: ______________________________________ Grade: ____________
Concerns/Reason for referral:
_____________________________________________________________________________________
_____________________________________________________________________________________
Referred By: __________________________________________
Has your child received speech-language therapy before? YES NO
If YES, please attach most recent evaluation and discharge summary.
DEVELOPMENTAL AND MEDICAL HISTORY
What is your child’s current mode of communication? Please mark all that apply.
point/gesture imitation single words
two-word phrases three and four-word phrases complete sentences
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