Speech-Language Pathology Intake Forms & Patient Questionnaires

A speech-language pathologist treats a wider range of conditions than most people realize. Articulation disorders in children, stuttering and cluttering in adolescents, voice disorders in teachers and singers, aphasia after stroke, dysarthria from Parkinson’s disease, pragmatic language deficits in autism spectrum disorder, and dysphagia across all age groups — each of these requires a fundamentally different clinical history and assessment approach. A generic medical intake form gives you a medication list and an allergy section, but it tells you nothing about when the child produced their first word, whether the adult patient’s voice worsens after a full day of teaching, or whether the stroke survivor can swallow thin liquids safely. The Speech Therapy intake form captures the clinical detail that drives your evaluation plan from the first session.

The form begins with the referral and presenting concern. It documents the referral source (pediatrician, neurologist, ENT, school district, self-referral), the primary communication concern in the referrer’s words, and how long the concern has been present. For pediatric patients, it captures who first noticed the problem — parent, teacher, daycare provider, or pediatrician — and at what age. For adult patients, it documents the onset event (stroke, traumatic brain injury, progressive neurological diagnosis, surgery, or gradual decline) and the date of onset, because the timeline between onset and the start of therapy directly affects prognosis and treatment intensity.

Communication Disorder Classification

The disorder classification section uses a detailed checkbox grid organized by communication domain. Articulation and phonology checkboxes cover sound substitutions, omissions, distortions, and phonological processes (fronting, stopping, cluster reduction, final consonant deletion). Fluency checkboxes capture stuttering (blocks, prolongations, repetitions), cluttering, secondary behaviors (eye blinking, head nodding, jaw tension), and avoidance patterns. Voice disorder checkboxes document hoarseness, breathiness, pitch abnormalities, vocal fatigue, vocal nodules or polyps, paradoxical vocal fold movement, and spasmodic dysphonia. Language checkboxes distinguish receptive language (comprehension of directions, vocabulary, complex sentences) from expressive language (word retrieval, sentence formulation, narrative skills, written expression). A separate pragmatic/social communication section covers eye contact, turn-taking, topic maintenance, figurative language comprehension, and perspective-taking.

For pediatric patients, the form captures developmental milestones that contextualize the current concern. It asks when the child babbled, produced first words, combined two words, and used sentences. It documents motor milestones (sitting, crawling, walking) because motor and speech development are neurologically linked. It asks about feeding history in infancy — breastfed or bottle-fed, any difficulty latching, transition to solids, gagging or choking on textures — because early feeding difficulties often correlate with oral motor weakness that shows up later as articulation problems.

Hearing, Oral Motor, and Feeding Assessment

Hearing screening history gets its own section because undetected hearing loss is the most common misdiagnosed cause of speech and language delays. The form documents newborn hearing screening results (pass, refer, not done), most recent audiological evaluation (date and results), history of ear infections (frequency, tubes placed, age at placement), and whether the patient currently wears hearing aids or cochlear implants. If no audiological evaluation has been done, the form flags this as a prerequisite before initiating speech therapy — because treating an articulation disorder in a child who cannot hear the target sounds is clinically futile.

The oral motor assessment section captures structural and functional information that affects speech production. It documents dental status (missing teeth, malocclusion, orthodontic appliances), tongue mobility (can the patient elevate the tongue tip to the alveolar ridge, lateralize, protrude), lip seal and strength, palatal integrity (history of cleft palate or submucous cleft, velopharyngeal insufficiency), and jaw stability. For patients with feeding and swallowing concerns, the form captures current diet texture (regular, mechanical soft, pureed, thickened liquids), swallowing complaints (coughing during meals, food sticking, wet vocal quality after swallowing, unexplained pneumonia), and weight changes.

Educational and Bilingual Considerations

For school-age patients, the form captures the educational context. It asks whether the child has an IEP (Individualized Education Program) or IFSP (Individualized Family Service Plan), the current speech-language goals on the plan, frequency and duration of services, and whether the child receives speech therapy through the school, privately, or both. It documents the child’s academic performance in reading, writing, and oral participation, because language disorders often present as academic difficulties before they are identified as communication deficits. The form captures classroom accommodations already in place (preferential seating, extended time, visual supports, FM system) and whether the child has been evaluated for or diagnosed with ADHD, learning disabilities, or autism spectrum disorder.

Bilingual and multilingual considerations are critical and frequently overlooked. The form asks which languages are spoken in the home, which language the child heard first, which language the child uses most, and whether the communication concern is present in all languages or only in English. This distinction matters because a bilingual child who produces speech errors only in their second language may be demonstrating normal second-language acquisition patterns, not a disorder. The form documents interpreter needs for the evaluation session and whether the caregiver prefers to communicate in a language other than English.

Caregiver Goals and Prior Treatment

The caregiver goals section asks what the family most wants to change, what situations are most frustrating for the patient, and what the patient can do well communicatively. It captures prior speech therapy history: where, for how long, what goals were targeted, and what progress was made. For patients who have had therapy before, it asks why services ended (goals met, insurance exhausted, moved, dissatisfied) and what the family felt worked or did not work in previous treatment — because this shapes how you approach the therapeutic relationship and set expectations for the current episode of care.

Pricing

Each form is $19.99 for the complete set (intake + questionnaire), $14.99 for intake only, or $9.99 for questionnaire only. All PDFs are fillable in Adobe Reader, password-protected against editing, and HIPAA-compliant.

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