• Child Intake Form

  • Dear Parent or Guardian, 

    Please make sure you have at least 20 minutes available to complete this form. Please email copies of the following documents to your therapist or to lanag@tplspeech.com or fax them to (503) 893-3063:

    • Speech-language evaluations, hearing tests, recent medical physical, and/or relevant medical evaluations (e.g., autism diagnosis).
    • Previous speech therapy progress reports, IEPs, IFSPs.

    PLEASE RETURN THIS INFORMATION TO YOUR THERAPIST BEFORE YOUR INITIAL APPOINTMENT

  • ***Active Military/Veterans: With proof of service, we offer a free evaluation to active duty/veteran families. Please let your therapist know if you qualify.***

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  • Child's Insurance Information

  • Pediatrician Information

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  • Child's Health Background

  • Child's Speech and Language Development

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  • Child's Strengths and Favorites

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