Patient Information
- Full Name: _________________ Date of Birth: _________________
- Gender: □ Male □ Female □ Other Preferred Pronouns: _________________
- Address: ________________________________________________
- Phone: (Home) _____________ (Cell) _____________ (Work) _____________
- Email: ________________________________________________
- Emergency Contact: _________________ Phone: _________________
Insurance Information
- Primary Insurance: _________________ ID#: _________________
- Secondary Insurance: _________________ ID#: _________________
- Policy Holder Name: _________________ Relationship: _________________
Medical History
Current Symptoms/Concerns (check all that apply):
□ Articulation difficulties
□ Language delays
□ Voice problems
□ Swallowing difficulties
□ Fluency/stuttering
□ Cognitive-communication issues
□ Other: _________________
Medical Background
- Primary Care Physician: _________________ Phone: _________________
- Current Medications: ________________________________________________
- Previous Speech Therapy? □ Yes □ No
If yes, when and where: ________________________________________________
- Relevant Medical Diagnoses: ________________________________________________
Developmental History (if applicable)
- Birth History: □ Full-term □ Premature (weeks: _______)
- Developmental Milestones: □ On time □ Delayed
- First Words Age: _________________
- Current Language(s) Spoken: _________________
Authorization
I hereby authorize the release of any medical information necessary to process insurance claims and authorize payment of medical benefits to the speech therapy provider.
Signature: _________________ Date: _________________
Office Use Only
- Received by: _________________ Date: _________________
- Insurance Verification: □ Complete □ Pending
- Initial Evaluation Date: _________________