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Intake Form: Speech with Wit
Please complete this form at least 24 hours prior to the first session. It should only take about 5 minutes to complete.
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Email
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Your email
Parent/Guardian's name(s):
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Your answer
Mailing Address:
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Your answer
Phone Number:
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Your answer
Language spoken in the home:
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Your answer
Child's name (first and last):
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Your answer
Child's Date of Birth:
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MM
/
DD
/
YYYY
What are the areas of concern?
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Articulation / Speech Sound Production (How the child pronounces sounds and words)
Receptive or Expressive Language (How the child understands and uses words to communicate)
Fluency (Stuttering, difficulty getting words out)
Augmentative and Alternative Communication (AAC)
Social Skills / Pragmatics (How the child uses language socially)
Other:
Required
Please provide EXAMPLES of errors / areas of concern.
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Your answer
Describe any relevant medical history (including hearing screenings/test, PE tubes, medical diagnoses, complicated pregnancy, etc)
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Your answer
What are your main goals/hopes to get from services?
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Your answer
Does the child receive any other speech-language therapy supports or services?
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Yes (If yes, please provide more information at the end of the form)
No
Other:
Does the child receive any other support services such as ELL, special education, Title I reading, tutoring, etc?
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Yes (If yes, please provide more information at the end of the form)
No
Other:
Please share any additional information you think would be relevant to this child.
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Your answer
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