New Client Intake Form

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New Client Intake Form
How did you hear about us?*

Social MediaFriends/Family/ColleaguesNewspaper/Online ArticleOnline SearchFormer Speech Language PathologistSchool StaffMedical Professional/ProviderNextDoor AppOther
Who will be receiving services?*

Child (Ages: 0 - 17 years old)Adult (Ages: 18 years old & Up)
Type of Service*

Speech Evaluation/DiagnosisIndividual TherapyGroup Therapy (Ages 6 & Up)A Hearing Screening (For ages: 0 - 7 years and 11 months old)
Type of Group Program

Language & Literacy Group for Ages 6-8: Thursdays at 5 to 6:00 PMSocial Thinking Group for Ages 11-14: Tuesdays/Thursdays at 5 to 6:00 PMSocial Thinking Group for Ages 15-18: Tuesdays/Thursdays at 5 to 6:00 PM
Type of Service*

Individual Speech TherapyIndividual Voice TherapyGroup Therapy
Type of Group Program*

Aphasia Conversation Group: Fridays at 9 to 10:30 AMBrain Health Group: Tuesdays at 12 to 2:00 PMStuttering and Cluttering Conversation Group (Hybrid): Tuesdays at 5:00 PM
Who am I?*

I am the clientI am representing the client
Representative's Name*

First NameLast Name
Relationship with the Client*
What are your goals for voice therapy?*

Improve Voice QualityGender-Affirming Voice CareHelp with a Voice Disorder

General Information
Date

MonthDayYear
Date
Client's Name*

First NameMiddle InitialLast Name
Preferred Name to Use in the Clinic:*

First NameMiddle InitialLast Name
Current Occupation*
Please provide an estimate of your annual income. (This data is used for statistical purpose only for further funding for our clinic. It does not affect your eligibility for our services.)*

$0 - $5,000$5,001 - $15,000$15,001 - $25,000$25,001 - $35,000$35,001 - $45,000$45,001 - $55,000$55,001 - $65,000$65,001 - $75,000$75,001 - $85,000$85,001 - $95,000$95,001+Other
Language(s) Spoken (Click any that apply)*

EnglishSpanishPolishFrenchArabicOther
Gender*
Pronouns*
(He/Him, She/Hers, They/them, etc)
Date of Birth*

MonthDayYear
Date
Age
Parent/Guardian (1)*

First NameLast Name
Relationship to the client.*
(Mom, Dad, Legal Guardian, Child, Caregiver, etc.)
Parent/Guardian's Occupation*
Please provide an estimate of your annual income. (This data is used for statistical purpose only for further funding for our clinic. It does not affect your eligibility for our services.)*

$0 - $5,000$5,001 - $15,000$15,001 - $25,000$25,001 - $35,000$35,001 - $45,000$45,001 - $55,000$55,001 - $65,000$65,001 - $75,000$75,001 - $85,000$85,001 - $95,000$95,001+Other
Parent/Guardian (2)

First NameLast Name
Relationship to the client.
(Mom, Dad, Legal Guardian, Child, Caregiver, etc.)
Parent/Guardian (2)'s Occupation
Please provide an estimate of your annual income. (This data is used for statistical purpose only for further funding for our clinic. It does not affect your eligibility for our services.)

$0 - $5,000$5,001 - $15,000$15,001 - $25,000$25,001 - $35,000$35,001 - $45,000$45,001 - $55,000$55,001 - $65,000$65,001 - $75,000$75,001 - $85,000$85,001 - $95,000$95,001+Other
Language(s) Spoken at Home (Click any that apply)

EnglishSpanishPolishFrenchArabicOther
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Preferred Contact Method*

Phone CallEmailBoth
I give my consent for a Voicemail/Text to be left on the telephone numbers listed above*

YesNo
I understand that email communication may not be secure. I give my consent to be contacted via email regarding clinic services via the email above.*

YesNo
When is the best time to call?*

Our Clinic's current Fall 2024 operating hours are Monday 1:00-5:00pm, Tuesday 8:00am-5:00pm, Wednesday 2:30-4:30pm, Thursday 8:00am-4:00pm. We are not currently open on Fridays. What is your availability for weekly appointments? (Check all that apply)*

	Monday	Tuesday	Wednesday	Thursday	Friday
8:00 AM to 11 AM
11:00 AM to 1 PM
1:00 PM to 3 PM
3:00 PM to 5 PM
5:00 PM to 6 PM

Please list any planned dates that might impact your appointments. (Vacation, Out of Town/State, etc.)
Vacation, Out of State, etc.

Family and Provider History
Have you received an evaluation by Otolaryngologist/ENT?*

YesNo
Individuals experiencing voice difficulties should make an appointment with an otolaryngologist (ENT) prior to the initiation of services.
Otolaryngologist/ENT's Name*

First NameLast Name
Otolaryngologist/ENT's Phone Number
Please enter a valid phone number.
Otolaryngologist/ENT's Clinic Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Recent Date of Otolaryngologist's Visit*

MonthDayYear
Date
Results of Videostroboscopy:*
Have you recently experienced any changes in your general health? Have you undergone surgery?*

YesNo
Please Explain*
Have you had any treatment for this or other voice problems?*

YesNo
When? Where and for how long? Please Explain*
Does anyone in your family have a history of voice problems?*

YesNo
Please explain*

My Emergency Contacts

	Family Members / Caregivers / POA	Check if Legal Guardian / POA	State the Relationship	Their phone number	Check if this person lives with the client
1
2
3
4
5

Primary Physician*

First NameLast Name
Physician's Office Number*
Please enter a valid phone number.
Please upload any related documents from a health care provider or Speech Pathologist. (i.e. clinic notes, progress reports, referral, face sheet, etc.)

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If you don't have a copy of the documents, please requested from your medical provider or speech therapist. You can email the forms to slpclinic@depaul.edu or fax it at 312-476-3339.
Is there any family history (including siblings) of speech, language and/or learning difficulties? If so, please describe:*

Please indicate the family members from previous question.

	Name	Relationship to the Client	Age
1
2
3
4

Is your child currently in any kind of school? (preschool, kindergarten, elementary, etc.)*

YesNo
School*

School's NameGrade
Type of Classroom*
* Montessori, General Education, Special Education, etc.
School Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Does your child have IEP?*

YesNo
Do you have IEP meeting scheduled?*

YesNo
When is the IEP Scheduled?*
Please provide a copy of the IEP*

Cancelof
Has your child had any previous evaluations or testing?*

YesNo
If yes, please list/explain, giving dates and locations of evaluation:*
Please provide all copies of the evaluation(s).*

Cancelof
Was your child given a diagnosis or were any labels used to describe your child’s strengths or difficulties as a result of the evaluation/testing?*

YesNo
If yes, please list/explain:*
Has your child received speech therapy services outside of school?*

YesNo

Treatment History*

	Therapy	Date	Location
1
2
3
4

Comments about Treatment History
Please provide any available reports from these sources. (Evaluation, Progress Notes, etc.)*

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Our clinic will need the necessary reports before moving forward with the next steps. Please requested it from your medical provider or speech therapist. You can email the forms to slpclinic@depaul.edu or fax it at 312-476-3339.

Child Developmental History
Chief Concerns: Please tell us about why you are coming to this clinic. What are your concerns about your child’s communication? What are your expectations for this clinic experience? *
i.e. receptive and expressive language (what a child understands and is able to express), Articulation (Speech Sounds), Fluency (stuttering), or pragmatic (social skills and language)
How does your child usually express him/herself?*

Actions (e.g., crying, pulling an adult's hand, pushing an adult's body)Sounds (e.g., babbling)Gestures (e.g., pointing)1-2 word sentences2-4 word sentencesComplete SentenceOther
How often can you understand what your child is saying?*

All the timeMost of the timeSome of the timeAlmost Never
Comments:
How can others (e.g., teachers, extended family members) understand what your child is saying?*

All the timeMost of the timeSome of the timeAlmost Never
Comments:

Are any of the following a concern for your child?*

	Yes	No
Expresses frustration when trying to communicate
Has difficulty pronouncing certain sounds
Has difficulty answering questions
Has difficulty following directions
Struggles to convey clear message when speaking, even if words are easy to understand
Gets stuck on or repeats words when talking
Has difficulty with his/her voice, vocal quality or breathing
Has a hard time making friends
Has difficulty understanding and following social rules

Please explain any “yes” answers about your concerns. Please give examples.
Birth/Health History
Please explain any difficulties before, during or after the birth of your child*
Please explain any current medical concerns.*
Please list any medications your child takes regularly.*

Hearing*

	No	Yes	Please Comment/Explain if yes
Have you ever had concerns about your child’s hearing?
Does your child use any amplification or other devices to aid hearing?
Does your child have frequent ear infections?

Vision*

	No	Yes	Please Comment/Explain if yes
Have you ever had concerns about your child’s vision?
Does your child currently wear corrective lenses?

Other Developmental Concerns

Please indicate if you have had in the past or currently have any concerns in the following areas of development:*

	Current Concern	Past Concern	Never a Concern
Motor (e.g., crawling, sitting, walking, running, clumsiness)
Self-help (e.g., dressing, toileting)
Feeding (e.g., drooling, choking, sensitivity to textures)
Early play (e.g., using toys appropriately)

Please explain any concerns indicated:
Speech & Language Development

At what age (approximate) did your child begin to do the following:*

	Age
Babble (sound combinations such as “bababa” or “gaga”)
Say first word
Jabber in nonsense sentences that sound like adult language
Begin to put words together (e.g, “Mommy play”, “want drink”)
Use complete sentences

Health History
Have you have any significant Illness/Surgeries?*

YesNo
Please explain*
Do you have any allergies?*

YesNo
Please indicate the following allergies.*
Do you have Asthma?*

YesNo
Please explain.*

Please indicate if your voice problem interferes with the following categories. (If it doesn't interfere, please write no.)*

	Check if applies	Mild, Moderate, or Severe
Work
Participating in Daily Activities
Socialize
Sing

What is your daily water/non-caffeinated beverages intake? (e.g., water, fruit juices, milk, herbal tea, etc.? Estimate the number of glasses per day calculating 8 oz. per glass.*

Less than 2 glasses3-4 glasses5-7 glasses8 or more glasses
What is your daily caffeine intake? (Coffee, Tea, Colas, and others)*

Less than 2 glasses3-4 glasses5-7 glasses8 or more glassesNone
What is your daily alcohol servings?*

1234NoneOther
Do you smoke?*

Non-smokerCurrently smokingFormer Smoker
At what age did you quit?*

Smoking History*

	Check if applicable	Age	How many per day?	Per Week?
Cigarettes
Pipe
Cigar
Chewing Tabacco
Smoke Recreational Drugs

Are you taking any medication?*

YesNo
If yes, please explain*
Do you have a reflux history?*

YesNo
What was the diagnosis?*

Gastroesophageal Reflux DiseaseLaryngopharyngeal RefluxOther
What are your symptoms?*
What is the frequency of symptoms?*

Reflux Management

	Check	Please explain
Behavioral
Medication
Dose

What are your expectations regarding the voice evaluation? What do you hope to gain from this evaluation?*
What do you want to be able to do with your voice after voice therapy? Be specific (for example: get through a week of teaching without vocal fatigue or hoarseness).*
How serious is your voice problem?*

0

1

2

3

4

5

6

0 is Worst, 6 is Best
What is the impact your voice problem has on your life?*

0

1

2

3

4

5

6

0 is Worst, 6 is Best

Vocal Activities

	Check If It Applies:	Please explain
Telephone without headset
Telephone with headset
Telephone with speakerphone
Talking: one to one conversation
Talking in noisy settings
Talking to groups
Yelling or cheering
Whispering
Imitating Others
Throat clearing
Coughing
Phonation during exercising
Singing
Other

Environmental Factors

	Check If It Applies:	Please explain
Smoke
Chemicals
Allergens
Temperature changes

Are you a vocal performer?*

YesNo
Vocal Training Type*
Number of Years Performing*
Singing Range*
Type of Music Performed*
Type of Accompaniment*
Type of amplification used when performing:*
Performance Venues*
Amount of practice per week:*
Warm up/cool down regimen: *
Voice Use History
Do you ever lose your voice?*

YesNo
Does the quality/sound of your voice change of its own accord?*

YesNo
Does your throat feel sore after you have talked for a long time?*

YesNo
Have you attempted to change your voice on your own?*

YesNo
How successful were these attempts?*
Goals
Describe what you hope gender affirming voice care can accomplish for you.*
Are you comfortable in one-on-one or group therapy sessions?*

One-on-One SessionsGroup Therapy SessionsBoth
Do you have any previous experience with gender affirming voice training?*

YesNo
Please explain your previous experience.*
In what situations would you like to use your voice? Do you need to use your voice over background noise?*

Adult Health History & Skills
Reason for referral: Please explain your main concerns with your communication skills. Why are you seeking speech language services? (Give examples)*
Medical History: Please check all that apply or check none.*

StrokeHypertensionPneumoniaTBICOPDDevelopmental DelayDiabetesDrug AbuseKidney diseaseAlcohol AbuseDementiaCancerVascular diseaseMultiple SclerosisDepressionDysphagiaHypotensionParkinson’s DiseaseHeart DiseaseNicotine UseNoneSeizure DisorderOther
Communication Diagnosis, if known: Please check all that apply or check none.*

AphasiaVoice DisorderApraxia of SpeechSpasmodic DysphoniaDysarthriaFluency/StutteringCognitive-Communication DeficitNoneOther
Would you be interested in participating in a book club? (Every Tuesday at 10 AM)*

YesNo

Please list previous speech-language evaluation and/or therapy (e.g., school, clinic, hospital, etc.)

	Services Rendered	When?	Where?
1
2
3

Communication Skills

Please check all areas that apply and provide additional information as needed to describe yourself or your loved one who is applying for services:
Understanding*

Follows all conversations all of the timeFollows conversations some of the timeUnderstands short, simple directionsDoes not usually understand conversationDo not knowOther
Speaking*

Uses sentences all of the timePuts 2-3 words togetherUses some wordsUnable to say words.Uses Communication DeviceOther
Reading*

Reading BooksReads sentences (e.g., headlines, labels)Reads magazines and newspapersReads wordsDoes not readDo not knowOther
Writing*

Writes notes and lettersWrites sentencesWrites wordsWrites namesDoes not writeDo not knowTypes or uses a computerOther
Daily Living Skills

Check any additional areas that are challenging and provide additional information as needed:
Skills*

Remembering names/wordsMaking good judgments/decisionsRemembering important/new informationManaging budgets/money/expensesLearning new routines/skillsManaging timeRemembering where items are locatedSolving problemsPaying attentionPlanningStaying safeMaking appointmentsAttending to both left and rightMaking phone callsOther
Following Directions*

VisualSpokenMapsGetting lost in unfamiliar locationsOther
Other Information and Concerns: Additional comments or information you would like to share with us (e.g., scheduling information/conflicts, pending surgeries, etc.)*
Do you use any of the following mobility aids?*

CaneCrutchesRollatorsWalkerWheelchairNone of the above.
Have you fallen within the past 12 months?*

YesNo
Do you feel unsteady when standing or walking?*

YesNo
Are you worried about falling?*

YesNo
Are you currently working?*

YesNo (Please explain)
If you have stopped working, do you plan to go back to work? Please explain:*

YesNo
Please explain*
Are you receiving assistance with vocational planning through an agency such as the Dept. of Vocational Rehabilitation?*

YesNo
Should be Empty:

New Client Intake Form

General Information

Family and Provider History

Child Developmental History

Birth/Health History

Other Developmental Concerns

Speech & Language Development

Health History

Voice Use History

Goals

Adult Health History & Skills

Communication Skills

Daily Living Skills