Speech Therapy Intake Form

Speech Therapy Intake Form — Form Fields

This healthcare template includes 8 fields. Gathers communication history and concerns for patients seeking speech-language therapy. Free to customize and use on ZenBuild.

• Patient Full Name (text, required)
• Date of Birth (text, required)
• Referring Physician (if applicable) (text, optional)
• Communication concerns (select all that apply) (checkboxes, required) — options: Stuttering / fluency, Articulation / pronunciation, Voice / vocal quality, Language comprehension, Language expression, Swallowing difficulty, Aphasia (after stroke/injury)
• How long have these concerns been present? (dropdown selection, required) — options: Since birth / early childhood, Less than 6 months, 6–12 months, More than 1 year
• Has the patient received previous speech therapy? (multiple choice, required) — options: Yes, No
• Describe the primary communication difficulty in detail (long text, optional)
• Relevant medical or developmental history (long text, optional)