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Adult Intake Form / History

Client's Name *

First

Last

Nickname

Date of Birth *

Age *

Gender

Male
Female
Prefer Not To Respond

Diagnosis (If Known)

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Email *

Marital Status

Single
Married
Widowed
Divorced

If under 18, Name of Parent/Guardian

Name of Spouse or Closest Relative

Permission to Contact

Yes
No

Others Living In the Home

Are You Receiving Any Assistance In The Home?

Yes
No

Describe Assistance Received

Language(s) Spoken

Client's Physician

Physician Phone Number

Physician Address

Address Line 1

Address Line 2

City

State

Zip Code

Other Physicians / Specialists Involved In Care

Employment Status

Employed
Self-Employed
Retired
Unemployed

Occupation

How Did You Hear About Us?

Current Status

Please Describe Your Present Concern

Is Your Communication Difficulty Related To Your Work?

Yes
No

Is Your Communication Difficulty Related To An Accident?

Yes
No

Briefly Describe Why You’re Seeking An Evaluation By A Speech-language Pathologist At This Time

What Do You Think Caused Your Speech Problem?

What Are You Expecting Out Of This Evaluation / Meeting?

Have You Ever Had A Previous Speech, Language Or Feeding Evaluation / Treatment?

Yes
No

By Whom?

When?

Describe The Results

Are You Currently Working With Another Provider?

Yes
No

Provider Contact Information

Has The Problem Improved Or Gotten Worse? Describe

When Did You First Notice The Problem?

How Does Your Communication Difficulties Impact Your Life, Social, Work, Hobbies, Etc.?

What Strategies Do You Use To Help Cope With This Problem?

Does Anyone In Your Family Have A History Of The Same (Or Different) Communication Difficulty?

Background & History

Describe Any Pertinent Information Regarding Your Medical History (Birth Injuries, Abnormalities, Surgeries, Diagnoses, Etc.) As Well As When They Were Diagnosed And By Whom

Describe Your Current Health Status

Have You Ever Had Surgery For A Related Issue?

Yes
No

Please Describe

Have You Ever Been Hospitalized For A Related Issue?

Yes
No

Please Describe

Have You Ever Been In A Serious Accident?

Yes
No

Please Describe

Do You Have A Chronic Illness? If So, Please Describe

Are You Currently On Any Medications? If So, Please List Medication Name And Reason For Medication

Do You Have Any Physical Disabilities?

Do You Currently Use Any Equipment? (Communication Device, Walker, Etc.)

Check All That Apply

Allergies
Asthma
Attention Deficit Disorder
Auto Accident
Brain Injury
Breathing Problems
Cancer
Cardiac Issues
Cleft Palate
Cognitive Concerns
Degenerative Illness
Depression
Developmental Delay
Diabetes
Ear Infections
Encephalitis
G-Tube
Hearing Loss
Pneumonia
Psychiatric Concerns
Respiratory Problems
Seizures
Stroke / TIA
Swallowing Problems
Other

Additional Details

Have You Ever Been Evaluated By The Following Specialties? Check All That Apply

Audiologist
Gastroenterologist
Occupational Therapist
Otolaryngologist
Physical Therapist
Psychologist
Psychiatrist
Speech Therapist

If Yes, Please Describe The Nature Of The Evaluation And Any Results

Highest Grade Completed

Degree Earned

Name of Institution(s)

Please upload copies of any previous evaluations or progress reports. You may also bring them in at our first meeting

Click or drag files to this area to upload. You can upload up to 3 files.

During School, Did You Have Any Problems With The Following? Check All That Apply

Attention
Behavior
Learning
Memory
Problem Solving
Reading
Speaking
Understanding
Writing

Additional Details

What Are Your Responsibilities In The Home? Check All That Apply

Cooking
Cleaning
Child Care
Driving
Finances
Laundry
Repairs
Shopping
Yard Work

Are There Any Questions You Would Like Us To Answer For You?

Is There Anything Else That Is Important For Us To Know About You?

Layout

Name Participant or Legal Representative *

Relationship To The Client *

Signature of Participant or Legal Representative *

Ready to Improve Your Speech & Language?

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Office: 32 Rolling Hills Ln, Harrison NY, 10528
Phone: 914-755-6373

Payment Methods Accepted:

2024 © Branched Out Therapy, Inc. All Rights Reserved.

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