Youth and Adult Intake Form

The information you provide on this form will be kept confidential. You may contact us at any time to request a copy of the information you have submitted to us. Please refer to our privacy policy for more details on how we store, use, and protect data here. Feel free to skip any questions you feel are not relevant or you would rather not answer.

* Indicates required field

Today's date *

I am completing this form for: *

Myself as the client Someone else as the client

If you are completing this form for someone else, please indicate your name and relationship to the client *

Name and address where invoices will be sent *

Name, relationship and details for client's emergency contact *

Client's legal name and age *

Client's preferred name *

Client's gender and pronouns *

Address where the client lives *

If the client is a student, please indicate their attending educational institution *

Please indicate if the client has any known disability or speech-language diagnoses *

Please indicate if the client has any medical conditions, allergies, seizures, other medical needs, or regular medications we should be aware of *

Is there anything the client would like us to be aware of in terms of their culture, ethnicity, values and beliefs or any other aspects of their identity? *

Does the client understand or speak any other languages besides English? *

What is the client's living situation? *

Names of key support people and their relationships to the client *

What family roles does the client have? For example: Mother, grandad, wife, son, aunt, brother, etc. *

What are the client's hobbies, interests, favourite people, places, activities, and things? *

Please indicate how the client participates in their community *

Please indicate what things are most important for the client's quality of life experience *

Is the client currently employed? If so, who is their employer and what is their line of work and job title? *

What is the client's highest level of education or qualification? *

Has the client been previously seen by a Speech-Language Therapist? If so, do we have permission to contact them? This allows us to coordinate care and also avoid repeating unnecessary assessment procedures. * *

Is the client currently receiving any support from other professionals or organisations? For example, physiotherapy, occupational therapy, counselling, etc. *

Please indicate the nature of the client's current communication problems and any relevant history regarding onset *

If the client's communication difficulties are the result of an accident, injury, stroke, or other medical event, please describe the person's oral language, reading, writing, and communication abilities as they were before this incident. *

How does the client communicate currently? *

If other, please explain *

What are the client's regular communication environments and communication opportunities? *

What everyday cognitive, literacy, oral language, or communication tasks are specifically problematic for the client? *

What barriers, participation restrictions, and activity limitations is the client experiencing as a result? *

What are the client's / client's family's priority goals for improvement? *

What interventions / strategies have already been tried? *

Any questions or concerns or additional comments? *

Submit

Site map

0508 SPEECHIE (0508 77 33 24) - [email protected]

The Speechie Centre
39 Cuba Street
Palmerston North 4412

Find us

YOUR CART