By the Templateez Team · Licensed Attorney · June 2026

Speech-Language Pathology Intake Forms: What SLPs Need to Capture at Patient Intake

A speech-language pathologist who walks into a first session without knowing whether the patient is a three-year-old with delayed first words or a 72-year-old recovering from a left-hemisphere stroke is not prepared to evaluate, let alone treat. The scope of SLP practice is enormous — articulation, language, voice, fluency, swallowing, cognitive-communication — and every one of those domains requires different history, different assessment tools, and different treatment planning. That breadth makes the intake form not just an administrative step but a clinical necessity.

Most SLP practices collect demographics and insurance. Some add a line for "reason for referral." That is not intake — that is registration. A real speech-language pathology intake form captures the referral chain, the patient's communication profile, developmental or neurological history, current functional abilities across every relevant domain, and the information your billing team needs to secure and maintain authorization. Here is what that form should include.

Referral and diagnosis: who sent this patient and why

SLP referrals come from pediatricians, neurologists, ENTs, audiologists, oncologists, primary care physicians, school teams, and self-referrals. The referral source shapes everything — a pediatrician referring a late talker is a fundamentally different case from an ENT referring a patient with unilateral vocal fold paralysis. Your intake should capture:

• Referring physician or provider — name, practice, phone, fax. You will need this for the evaluation report, progress notes, and any letters of medical necessity.
• Referral diagnosis and ICD-10 codes — the referring provider's working diagnosis drives your evaluation focus and is required for billing. Common codes span R47.1 (dysarthria), R13.10 (dysphagia), F80.1 (expressive language disorder), R47.02 (dysphasia), and dozens more. If the referral came without a code, you need to flag that before the first session.
• Prior authorization status — has the referral been pre-authorized by the payer? Authorization number, number of visits approved, authorization expiration date. Medicare, Medicaid, and most commercial plans require prior auth for SLP services, and treating without it means you are working for free.
• Specialist referrals in the chain — has the patient seen an audiologist, ENT, neurologist, or gastroenterologist related to this complaint? Results of those evaluations inform your assessment and prevent duplicating workup that has already been done.

Patient demographics: age changes everything

In few healthcare disciplines does patient age alter the clinical picture as dramatically as in speech-language pathology. A two-year-old, a 35-year-old, and an 80-year-old can all present with "difficulty communicating," but the etiology, assessment, treatment approach, and expected outcomes are entirely different. Your demographic section needs more than a date of birth:

• Date of birth and current age — calculated in years and months for pediatric patients, since the difference between 2;4 and 2;11 is clinically significant for developmental milestones.
• Gender — relevant to normative data for voice (fundamental frequency ranges differ), fluency (stuttering prevalence is 4:1 male to female), and certain language assessments with gender-normed scoring.
• Living situation — for pediatric patients, who is the primary caregiver? For geriatric patients, are they living independently, with family, or in a skilled nursing facility? The home environment directly affects carryover of therapeutic strategies.
• Education level — for adults, highest education completed. This contextualizes language and cognitive-communication assessment results. A college professor and a patient who left school at 16 have different premorbid baselines, and your evaluation needs to reflect that.

Communication profile: language, modality, and access

Before you assess someone's communication, you need to understand how they communicate right now — what language, through what modality, and with what supports:

• Primary language — the language spoken most at home. This is not optional information. Assessing a bilingual child's English-only output without understanding their total language system across both languages leads to overidentification of disorder where none exists.
• Other languages spoken — and the level of proficiency in each. Language dominance, age of acquisition of each language, and which language is used in which context (home vs. school vs. work) all affect assessment selection and interpretation.
• Interpreter needed — yes or no, and for which language. If the patient or caregiver requires an interpreter, this must be arranged before the evaluation, not discovered when they arrive.
• AAC device user — does the patient currently use an augmentative and alternative communication device or system? Type (high-tech speech-generating device, low-tech picture board, sign language, communication app), make and model if applicable, and proficiency level. An AAC evaluation is an entirely different workflow than a standard speech-language evaluation.

Speech and language history: developmental vs. acquired

This is where the pediatric-adult divide in SLP practice becomes most apparent, and your intake form needs to handle both populations. The history section should branch based on whether the communication concern is developmental or acquired:

Pediatric / developmental history. For children, the communication timeline is everything. Your intake should capture age of first words, age of first word combinations, whether babbling was present and varied, whether the child met motor milestones on time (sitting, walking — motor and speech development are correlated), history of ear infections (chronic otitis media during the language-learning window is a red flag), feeding difficulties in infancy, and any regression of previously acquired skills (a critical question that can indicate autism spectrum disorder or a neurological condition). Family history of speech, language, or learning difficulties is also relevant — many communication disorders have a hereditary component.

Adult / acquired history. For adults, you need the onset event and its timeline. A sudden onset of word-finding difficulty after a left MCA stroke is aphasia until proven otherwise. A gradual decline in speech clarity over 18 months in a 60-year-old may indicate a progressive neurological condition — ALS, Parkinson's, or primary progressive aphasia. Your intake should capture: date and nature of the onset event (stroke, TBI, surgery, progressive), hospital and treating physicians, imaging results if available (CT, MRI — lesion location matters enormously for prognosis in aphasia), prior SLP treatment and its outcomes, and the patient's own perception of what has changed and when.

Current communication abilities: the functional snapshot

Your evaluation will formally assess these domains, but the intake form captures the patient's and family's report of current functioning — which often reveals more about real-world impact than any standardized test:

• Receptive language — does the patient understand spoken language? Follow directions? Understand complex or multi-step instructions? For children: does the child respond to their name, follow simple commands, understand questions?
• Expressive language — can the patient express wants and needs? Use complete sentences? Find the words they want? For children: how many words, word combinations, sentence length?
• Pragmatic / social communication — does the patient maintain eye contact, take conversational turns, stay on topic, understand humor and sarcasm, read social cues? Pragmatic deficits are hallmarks of autism spectrum disorder in children and right-hemisphere damage or TBI in adults.
• Reading and writing — literacy is part of language. Alexia (acquired reading impairment) and agraphia (acquired writing impairment) often accompany aphasia and require assessment and treatment. For children, reading and writing milestones relative to grade level.
• Speech intelligibility — what percentage of the patient's speech is understood by familiar listeners? By unfamiliar listeners? This single metric often determines whether intervention is medically necessary for insurance purposes.

Voice and resonance

Voice disorders are a distinct clinical domain within SLP, and patients presenting with voice complaints require specific intake documentation that a general communication history will not capture:

• Voice quality — patient's description of the problem. Hoarseness, breathiness, roughness, strain, pitch breaks, voice fatigue, complete voice loss (aphonia). Duration and whether it is constant or intermittent.
• Pitch and loudness concerns — is the voice too high, too low, too quiet, too loud? Does the patient have difficulty being heard in noisy environments? Does the voice give out by the end of the workday?
• Vocal habits and risk factors — throat clearing, habitual coughing, yelling or screaming (coaches, teachers, parents of young children), singing (trained or untrained), whispering (which is actually more traumatic to the vocal folds than soft phonation), caffeine and hydration, smoking, reflux (LPR is a major contributor to voice disorders).
• Vocal fold pathology history — has the patient been scoped by an ENT? Results of laryngoscopy or stroboscopy. History of vocal fold nodules, polyps, cysts, paralysis, or granuloma. History of laryngeal surgery. History of intubation (a common cause of iatrogenic vocal fold injury).
• Professional voice use — is the patient a professional voice user? Teachers, clergy, attorneys, call center workers, actors, and singers have occupational demands on their voice that affect both treatment goals and prognosis.

Fluency: stuttering is more than disfluency

Fluency disorders require their own intake section because the history, the phenomenology, and the treatment approach are unlike anything else in SLP practice:

• Age of onset — when did the stuttering begin? Onset between 2 and 5 years is typical developmental stuttering. Onset after age 10 or in adulthood suggests neurogenic or psychogenic stuttering, which have completely different etiologies and treatment paths.
• Types of disfluencies — part-word repetitions, whole-word repetitions, prolongations, blocks (silent or audible). The type and frequency of disfluency inform severity rating and treatment planning.
• Secondary behaviors — head movements, eye blinks, facial tension, jaw tremor, fist clenching, foot tapping. These are learned escape and avoidance behaviors that often cause more social impact than the disfluency itself.
• Avoidance patterns — word substitutions, circumlocution, avoiding speaking situations (ordering at restaurants, answering the phone, speaking in class or meetings). Avoidance is the dimension of stuttering that most affects quality of life, and it is invisible on a standardized fluency test if the patient is successfully avoiding.
• Prior fluency therapy — what approach was used (fluency shaping, stuttering modification, avoidance reduction, combination), duration, and outcome. A patient who has had three rounds of unsuccessful fluency therapy needs a different approach, not a fourth repetition of the same one.

Swallowing and feeding: the dysphagia intake

Dysphagia management is a significant portion of SLP practice, particularly in hospitals, skilled nursing facilities, and home health. Swallowing disorders are also life-threatening in a way that communication disorders typically are not — aspiration pneumonia is a leading cause of death in the elderly and in neurologically impaired patients. Your intake must screen for:

• Current diet — diet texture level (regular, mechanical soft, pureed) and liquid consistency (thin, nectar-thick, honey-thick). Is the patient on a modified diet already? Who recommended it?
• Aspiration history — known aspiration events, history of aspiration pneumonia, recurrent pneumonia without clear cause (occult aspiration is often the answer).
• Feeding method — oral only, PEG tube (percutaneous endoscopic gastrostomy), NG tube, or combination. If tube-fed, is the goal to return to oral feeding?
• Weight loss — unintentional weight loss is a red flag for inadequate oral intake secondary to dysphagia. Amount and timeline.
• Mealtime observations — coughing or choking during or after meals, wet or gurgly voice quality after eating, food sticking in the throat, pain with swallowing, drooling, prolonged meal times, avoidance of certain textures.
• Prior swallowing studies — has the patient had a Modified Barium Swallow Study (MBSS/VFSS) or a Fiberoptic Endoscopic Evaluation of Swallowing (FEES)? Results, date, and recommendations.

The swallowing intake has natural overlap with other healthcare disciplines. Pediatric practices encounter feeding difficulties as part of developmental assessments, and occupational therapy intake forms capture feeding and self-care skills that intersect with SLP's dysphagia domain — particularly for pediatric feeding disorders where OT and SLP co-treat.

Hearing status

Hearing and speech-language development are inseparable. A child who cannot hear cannot learn language through the auditory channel. An adult who loses hearing gradually may develop compensatory speech patterns. Your intake needs:

• Audiogram results — date of last hearing test, type and degree of hearing loss if present (conductive, sensorineural, mixed; mild, moderate, severe, profound), configuration (bilateral, unilateral, high-frequency).
• Hearing devices — hearing aids (type, bilateral or unilateral, consistent use), cochlear implant (date of implantation, processor type, mapping history), bone-anchored hearing aid.
• Auditory Processing Disorder diagnosis — APD affects how the brain processes auditory information even when peripheral hearing is normal. An APD diagnosis significantly affects assessment selection and treatment approach for language and academic skills.
• History of ear infections — particularly relevant for pediatric patients. Chronic otitis media with effusion during the first three years of life can cause fluctuating hearing loss during the critical period for language acquisition.

Oral motor examination baseline

You will conduct a formal oral motor exam during the evaluation, but the intake form should capture relevant history so you know what to look for:

• Structural concerns — history of cleft lip or palate (repaired or unrepaired), submucous cleft, velopharyngeal insufficiency, tongue tie (ankyloglossia, and whether it has been released), dental malocclusion, missing teeth, dentures.
• Functional concerns — reported weakness or asymmetry of lips, tongue, or jaw. Drooling beyond age-appropriate norms. Difficulty chewing. Mouth breathing. Tongue thrust swallow pattern.
• Surgical history — tonsillectomy, adenoidectomy, jaw surgery, palatal surgery, tongue surgery. These directly affect the structures you will be examining and treating.

Pediatric-specific fields

For pediatric patients, the intake must extend into the educational and early intervention landscape:

• Current school and grade — and whether the child is in a general education classroom, self-contained special education, or a blend.
• IEP or 504 Plan — does the child have one? Does it include speech-language services? How many minutes per week, individual or group, push-in or pull-out? What are the current IEP speech-language goals?
• Classroom accommodations — preferential seating, extended time, visual supports, FM system, one-on-one aide, modified assignments. These tell you what the school team has already identified as needs.
• Early Intervention history — for children under 5, did the child receive Early Intervention (Part C) services? At what age did services begin? What services were provided (SLP, OT, PT, developmental specialist)? Transition to preschool special education (Part B)?
• Other therapies — is the child concurrently receiving occupational therapy, physical therapy, applied behavior analysis (ABA), or mental health services? Coordination across providers is essential for pediatric patients. Many pediatric patients receive both speech and occupational therapy — our occupational therapy intake guide covers the motor, sensory, and functional assessment fields that complement speech-language intake.

Treatment goals: what the patient and family actually want

Standardized assessments tell you what the deficits are. The patient and family tell you what matters. Your intake should capture:

• Patient and family priorities — what is the primary concern? What would they most like to change? A parent of a child with autism may care most about functional requesting, not articulation. A stroke survivor may care most about being understood by their spouse, not scoring higher on a naming test. These priorities should drive goal-setting.
• Functional communication goals — what does the patient need to do that they currently cannot? Return to work? Order at a restaurant? Participate in class? Talk on the phone? Eat a regular diet? These real-world targets are what make therapy meaningful and what justify continued services to payers.
• Discharge criteria — what does "done" look like? For some patients, it is age-appropriate communication. For others, it is functional communication with compensatory strategies. For progressive conditions, it may be maintaining current function as long as possible. Setting these expectations at intake prevents the open-ended therapy trap.

Insurance, authorization, and HIPAA consent

SLP services are heavily regulated by payers, and the administrative intake is as important as the clinical intake for keeping your practice financially viable:

• Insurance information — primary and secondary payer, policy number, group number, subscriber information. Medicare and Medicaid have specific documentation requirements for SLP services that differ from commercial plans.
• Visit limits and re-evaluation timelines — many plans cap the number of SLP visits per year or per authorization period. Medicare requires a re-evaluation to justify continued treatment. Your intake should capture the authorization window so you can plan treatment frequency and duration within it.
• HIPAA consent — the patient's signed acknowledgment of your Notice of Privacy Practices, consent to treatment, consent to share information with referring providers and the school (for pediatric patients), and any restrictions on disclosure. This is non-negotiable before the first session.

If your practice covers multiple rehabilitation disciplines, the Healthcare Bundle includes speech-language pathology alongside 20 other healthcare specialties, each with discipline-specific intake fields.