Speech Therapy Intake Form Template

Help your speech-language pathologists prepare for initial evaluations with a thorough digital intake form. This template gathers client demographics, communication concern type, history of prior therapy, and relevant medical background — for both adult and pediatric patients — so clinicians can begin with context rather than starting from scratch.

Use this template

Last updated 21 August 2026

Fields in this template

Client Full Namerequired
Date of Birthrequired
Email Addressrequired
Phone Numberrequired
Is this intake for an adult or child patient?required
Adult (18+) · Child / Minor
Parent or Guardian Name (if patient is a minor)
Primary Communication Concernrequired
Articulation / Speech Sounds · Fluency / Stuttering · Voice / Vocal Quality · Language Comprehension or Expression · Swallowing or Feeding Difficulties · Cognitive Communication · Other
Description of Communication Challengesrequired
Has the client received speech therapy before?required
Yes · No
Relevant Medical History
Were you referred by a physician or healthcare provider?required
Yes · No
Referring Physician Name (if applicable)

Who uses this template

Speech-language pathologistsPediatric therapy clinicsSchool-based SLP practicesAdult rehabilitation centersPrivate therapy practicesTelehealth speech therapy providers

About this template

A speech therapy intake form captures the clinical background that shapes an SLP's evaluation approach before the first session. Whether the concern is articulation in a toddler, stuttering in an adolescent, or voice changes in an adult, different presentations require different assessment tools — and knowing in advance which area is primary lets the clinician prepare accordingly.

For pediatric clients, the intake form also establishes the parent or guardian as the primary informant, which is essential for gathering developmental history, birth history, and information about how the communication difficulty affects the child's school and social life. For adult patients, particularly those recovering from stroke or neurological injury, collecting relevant medical history before the evaluation informs both assessment selection and treatment goals.

formformform lets speech therapy practices deploy a professional intake form that clients or parents can complete from home before the first appointment. Submissions are delivered to your inbox immediately, and the form can be embedded on your practice website or sent via a scheduling confirmation link — no paper, no fax, no phone tag.

12 form ideas you can build with this template

Pediatric Articulation Disorder Intake

Collects developmental speech milestones, phonological patterns observed by parents, and previous evaluations for children with speech sound disorders.

Adult Aphasia Rehabilitation Intake

Gathers stroke or brain injury history, current functional communication abilities, and prior speech therapy for adults with aphasia.

Stuttering Evaluation Intake Form

Asks about fluency history, severity in different speaking situations, emotional impact, and prior fluency therapy experience.

Voice Disorder Evaluation Intake

Collects vocal use patterns, occupation, smoking history, reflux symptoms, and prior ENT consultations for patients with voice concerns.

Pediatric Language Delay Intake

Captures developmental milestones, expressive and receptive language concerns, and bilingual status for children with suspected language delays.

Dysphagia Swallowing Evaluation Intake

Gathers medical diagnoses, diet texture current tolerance, mealtime observations, and aspiration history for patients with swallowing difficulties.

Autism Spectrum Communication Intake

Collects current AAC use, social communication challenges, behavioral context, and school or therapy support services for autistic clients.

Telehealth Pediatric Speech Session Intake

Asks about device availability, internet reliability, caregiver participation, and home practice capacity for remote pediatric speech services.

Corporate Voice and Presentation Coaching Intake

Gathers professional speaking demands, vocal fatigue patterns, presentation anxiety level, and coaching goals for executive clients.

Traumatic Brain Injury Cognitive Communication Intake

Documents TBI date, current cognitive concerns like memory and word finding, and return-to-work goals for post-TBI rehabilitation clients.

Early Intervention Speech Referral Form

Collects parent concerns, age-appropriate developmental milestones not yet met, and pediatrician referral details for children under age 3.

Cleft Palate Speech Evaluation Intake

Gathers surgical history, resonance concerns, and craniofacial team provider details for children with cleft palate and velopharyngeal dysfunction.

What's included

Adult vs. child patient toggle with conditional guardian name field

Primary communication concern dropdown covering all SLP domains

Open-text description of challenges with real-life impact

Prior speech therapy history question

Medical and developmental history field

Physician referral capture for insurance documentation

Works for both pediatric and adult populations

Embeddable on any therapy practice website

How to create a speech therapy intake form

1
Click 'Use this template' to open the speech therapy intake form in the formformform editor.
2
Add domain-specific fields — for example, a section for hearing history, AAC device use, or school/IEP information for pediatric clients.
3
Adjust required vs. optional fields based on your intake protocol.
4
Configure email notifications to route completed forms to the assigned SLP before the evaluation session.
5
Embed the form on your practice website or share the link in scheduling confirmation emails.
6
Review submissions before each session so the SLP arrives prepared for the specific communication concern.

Best practices for your speech therapy intake form

Use a dropdown for the primary concern category

it keeps responses structured and makes it easier to assign the right evaluations before the session begins.

Include a free-text description field alongside the dropdown

structured categories tell you the domain, but the narrative tells you the real-life impact and urgency.

Ask about prior therapy specifically

parents often minimize past services or forget to mention them, but knowing what has been tried affects goal-setting significantly.

Make the physician referral question required

many insurance payers require documentation of a physician referral for speech therapy services.

For pediatric forms, make the guardian name field optional but visible

some adult patients may also have a healthcare proxy or caregiver.

Include a hearing history question or link to a separate audiology intake

undetected hearing loss is a primary cause of speech and language delays and should be ruled out early.

Frequently asked questions

Can I customize this form for telehealth speech therapy?

Yes. Add a field asking what device the client will use for sessions (phone, tablet, computer) and whether they have a quiet private space available — both affect the quality of remote sessions.

How does this form handle pediatric vs. adult clients?

A radio question at the top asks whether the patient is an adult or a minor. If a minor, a parent/guardian name field appears. You can further customize by adding age-specific sections for developmental milestones or adult medical history.

Can I collect insurance information through this form?

Yes. Add short_text fields for insurance carrier name, member ID, and group number to capture the details your billing team needs before the first visit.

Is this form suitable for school-based SLP practices?

Yes, with customization. You can add fields for school name, grade level, teacher name, and IEP status to make it appropriate for a school-based intake context.

How do I receive completed intake forms?

Every form submission triggers an instant email notification to the address you configure. You can also view and export all submissions from the formformform dashboard.