Client Intake Form (Child)

Client Intake Form (Adult)

Policies & Procedures

Release of Information

Video Consent Form

Client Intake Form (Adult)

All of the information you provide will be kept confidential and will only be used for evaluative and therapeutic purposes.

You have two options for filling out the form:

1) Scroll down and fill in the form online and submit.

2) View, download, print, handwrite your responses and bring to your first meeting with Lucia Reardon.

Download Intake Form

Please note that Lucia Reardon Speech Language Pathology, LLC does not accept payment through insurance companies. Clients are provided with a monthly bill that may be submitted to their health insurance, if appropriate.

Clients must read, understand and agree to the terms and conditions in the Policies and Procedures of Lucia Reardon Speech Language Pathology, LLC. Clients will be provided with a printed copy and agree to be responsible for the payment for speech and language therapy treatment, evaluation and consultation services rendered as outlined to commence and receive services.

This form will be printed out at the time of the first consultation. The parent/guardian/client will sign and date it and the form will be retained in the client’s file.

Client Intake Form (Adult)

* Required information

Client Intake Form (Adult)

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Full Name*
Date of Birth
Home Address(Required)
Home Address*
Telephone Number*
Your Email Address(Required)
Your Email Address*

Health History

Have you received any specific diagnosis / diagnoses related to your interest in this practice's services?
Do you regularly take medication? If so, please indicate type of medication and reason for medication.

Educational/Professional Background

Please provide some details about your education (e.g. high school diploma, secondary education, advanced degrees).
Do you have a history of academic challenges?
Did you participate in so called "gifted programs"?
As a student in middle or high school, did you receive accommodations of any sort? Did you find them helpful?
Please provide any information you feel is pertinent about your education that helps to explain why you are seeking our services.
What jobs have you held, if any in the last few years?
If currently employed, what is your position and are you content in that position?
Please provide any information regarding your work or profession that you feel will be helpful and pertinent.

Executive Function Skills

Can you plan your day, identify priorities and stick to them?
Can you maintain systems for organizing your work?
Are you usually on time for appointments and activities?
Are you able to estimate how long it will take to complete a task?
Are you able to break large tasks or assignments into subtasks and timelines?
Do you frequently leave tasks or assignments until the last minute?
Are you able to adjust to changing circumstances or unexpected events in stride?
Is procrastination a problem for you? If yes, under what circumstances?
Do you struggle to set reasonable goals?

Social Cognitive-Communication Skills

What are your social strengths?
Can your child prioritize, initiate and execute tasks associated with homework?
Is your child able to estimate how long it will take to complete a task similar to peers?
Can your child break large tasks or assignments into subtasks and timelines?
Does your child consistently leave tasks or assignments until the last minute?
Is your child able to adjust to changing circumstances or unexpected events in stride similar to same age peers?
Do small things affect your child emotionally and distract him or her from tasks at hand?
Is procrastination a problem for your child?

Social History

How is your child doing socially in school?
Is your child invited to parties, or social events by peers?
Does your child have friends?
Does your child show understanding of the feelings of others?
Does your child understand of the body language and facial cues of others?
Is your child aware of how he/she appears to others?
Is your child able to engage in socially appropriate and reciprocal behavior and conversation with her or her peers in a variety of settings/situations?
What are your child's social strengths?
What are your child's social weaknesses?
Describe some specific social difficulties experienced by your child.
What are your child's interests and is he/she able to disengage from this/these activity/ies if asked to or is required to engage in a less preferred activity?
Overall, how would you describe your child (e.g. happy, nervous, sense of humor, etc.)?

Family History

Names and ages of child's siblings
Do you have any pets at home? If so, name and type
Is there any history of speech/language or learning difficulties in your family? If yes, please explain.
What language(s) are spoken in your home?

Evaluation History

Has your child been seen for a speech/language, learning, psychological or neurological evaluation? If yes, please explain the reason for the evaluation and briefly summarize the findings of the evaluation.
Is your child under the care of another professional (i.e. psychologist/psychiatrist/counselor)? Please specify and give the reason why.
Has your child received communication, social-cognitive or executive function therapy in the past? If yes, please indicate the type of therapy and the approximate dates of therapy.
Has your child ever received a hearing evaluation? If yes, please indicate when the evaluation was done, who conducted the evaluation and the general results of the evaluation.

Summary

What are your goals for your child?
Please provide any additional information or insight here that you consider important.
Signature
Signature Date
MM slash DD slash YYYY
This field is for validation purposes and should be left unchanged.