Pathway Speech and Language

New Client Information and Intake Form

Name _________________________________        Date of Birth _____________________

Age ________  Grade ______  School ___________________________________________

Referred By ___________________________________________________________________________

Parent’s Name ________________________________________________________________________

Address Line 1 _________________________________________________________________________

Address Line 2 _________________________________________________________________________

Home Phone ________________________  Cell Phone ____________________________

Email Address _________________________________________________________________________

Previous Testing By/When _______________________________________________________________

Primary Diagnosis from Testing ___________________________________________________________

OFFICE USE ONLY:

DSM IV Codes _________________________________________________________________________

Assigned Therapist ____________________________              Testing Date/Time _______________________

Tests to Be Given ______________________________________________________________________

Fees for Tests ___________________________

Notes Regarding Client:

Paperwork:  Date Mailed to Client _____________  Business Folder _____        Green Folder ____

Client Information Policies ______     Evaluation Questionnaire ______      Release of Information _____             

Debit/Credit Authorization Form ________