Initial Intake Form

The Initial Intake Form is the first component to a Comprehensive Speech-Language Assessment. It provides you as the caregiver an opportunity to provide information regarding the client’s medical status, education, socioeconomic, cultural, and linguistic background(s) and information from teachers, family, and other related service providers.  Please take your time completing this form and we will take our time reading it. You may be contacted by the evaluating Speech-Language Pathologist prior to the initial evaluation to discuss your child’s information obtained. Again thank you for your time and choosing Speech Pathway!

* Note if you have not completed our Check Benefits Form do not complete this form. Once you have completed the Check Benefits Form our office staff will be in contact with you with information to proceed.

Do not select “Save” unless you need to leave and come back to this form.