LNL Intake Form
Thank you for choosing LNL Speech Therapy! Please complete the form in its entirety and then click SUBMIT.
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Today’s Date *
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Child’s Name (First and Last) *
Child’s Date of Birth (Please select the correct year) *
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Sex
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Parent/Guardian Name #1 (First and Last) *
Relationship to Child *
Parent/Guardian phone #1  *
Parent/Guardian Email #1 *
Client Address (street, city, state, zip code) *
Parent/Guardian Name #2 (First and Last)
Parent/ Guardian #2 Relationship to Child
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Parent/Guardian Phone #2
Parent/Guardian Email #2
Emergency Contact Phone #1 *
Emergency Contact Phone #2 *
How did you hear about us? *
Physician/Pediatrician Name  *
Physician/Pediatrican Phone # *
Primary Language spoken home: *
Client’s Primary Language: *
Other Languages spoken home:
Treatment Location *
Name of Treatment Location  *
Address of Treatment Location  (street, city, state, zip code) *
Preferred Time of Service (Fridays Only, 9am-3pm)
Primary Concerns *
Please explain your concerns 
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