If you would like to request information regarding therapy, you may email the form below to us at
NEW CLIENT INTAKE FORM
Please use the form below to inquire about our services.
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 ________