New Client Intake Form

Please complete the following form to tell me about your child and their needs. All information provided is kept confidential.

Child's Information

Full Name*

Date of Birth*

Gender Identity (Optional)

Primary Language(s) Spoken at Home*

School/Kindergarten/Childcare Name & Year Level

NDIS Participant Number (If applicable)

NDIS Plan Dates (If applicable)

Parent/Guardian Information

Parent/Guardian 1 Full Name*

Parent/Guardian 1 Phone*

Parent/Guardian 1 Relationship to Child*

Parent/Guardian 1 Email*

Parent/Guardian 2 Full Name (Optional)

Parent/Guardian 2 Relationship to Child

Parent/Guardian 2 Phone

Parent/Guardian 2 Email

Home Address*

Primary Contact Person

Reason for Seeking Services

Who referred you?

Main Concerns*

Goals for Speech Therapy

Developmental & Medical History

Medical Conditions/Diagnoses

Developmental Milestones

Hearing Status

Vision Status

Other Therapies Received (Past/Present)

Communication Skills

How does your child typically communicate?

Does your child understand instructions?

Concerns about speech sounds/articulation?

Concerns about stuttering/fluency?

Concerns about voice quality?

Concerns about social interaction/play skills?

Feeding/Swallowing (If Applicable)

Concerns about eating, drinking, or swallowing?

Types of foods/textures accepted or refused?