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Page 1 of 14
1419 Forest Dr. Suite 206, Annapolis, MD 21403
P: 410-280-9788 F: 410-280-9790
E: manager@chesapeakespeechlanguage.com
Patient Intake Forms
Patient Information
Child Name: ______________________________________ Date of Birth: ____________________ Sex: ________________
Address
: ____________________________________________ City: _________________ State: _________ Zip: _________
Preferred Phone: ____________________________________ Secondary Phone: ____________________________________
Pediatrician: ______________________________________ Name of Office: _______________________________________
Referred By: ____________________________________________________________________________________________
Parent(s)/Guardian(s)
Name:______________________________________________ Date of Birth: ______________________________________
Primary Phone Number: _______________________________ Secondary Phone Number (optional): ___________________
C
heck if address is same as listed above. If address is different, please complete.
Address
:____________________________________________ City:________________ State: _________ Zip: ___________
Email(s): ______________________________________________ _______________________________________________
Name:______________________________________________ Date of Birth: ______________________________________
Primary Phone Number: _______________________________ Secondary Phone Number (optional): _________________
__
C
heck if address is same as listed above. If address is different, please complete.
Address
: ___________________________________________ City: ________________ State: _________ Zip: ___________
Email(s): ______________________________________________ _______________________________________________
Select
Select
Select
Page 2 of 14
Insurance Information
Insurance Guarantor Information (Insurance patients only - please bring insurance card to first appointment)
Name of Insurance Subscriber: ____________________________________ Date of Birth: ____________________________
Address
: ___________________________________________ City: ________________ State: _________ Zip: ___________
Relationship to Patient: ________________________ Phone Number: ___________________ SSN: ____________________
Primary Insurance Information
Insurance Company: _______________________________________ Phone Number: ________________________________
Policy or ID Number: _______________________________________ Group Number: ________________________________
Insurance Billing Address: ____________________________ City: _______________ State: ____________ Zip: ____________
Medical Insurance Authorization
I am an authorized beneficiary of the above insurance plan. I confirm that all the above information is accurate, and I agree
to notify Chesapeake Speech Language Associates, LLC of any changes. I hereby authorize Chesapeake Speech Language
Associates, LLC to submit claims on my behalf and to release any information acquired in the course of my examination or
treatment necessary to process my claims.
_________________________________________________ ______/______/______ ________________________________________
Signature Date Relationship to Patient
click to sign
signature
click to edit
Page 3 of 14
CURRENT CONCERNS
Reason for today’s visit:
Please check all that apply
Speech
Language
Fluency
Feeding
Voice
Stuttering
Social Skills Reading Skills Writing Skills
Select any evaluations within the last
6 months? If yes, please have results
forwarded to our office prior to
evaluation.
None
Speech/Language
Physical Therapy
Occupational Therapy
Other (e.g. ENT, Neuro, Psychology) ______________________________
When
? _____________________ Where? __________________________
Describe any speech, language and/or
feeding concerns:
When was the difficulty first noticed?
How does this impact your child?
How do you and your family members
react to this difficulty?
What are your goals for treatment?
Check any special equipment used by
your child:
Wheelchair Braces Walker Eyeglasses Hearing Aids
Communication Device or System Other _______________________
If communication device or system used, please name system used:
Page 4 of 14
FAMILY BACKGROUND
Other children in the family:
________________
______ _____ ______________________ _____
________________
______ _____ ______________________ _____
Please share any pets’ names or
items that are important to your
child e.g. toy, blanket, stuffed
animal etc.
______________________________ ______________________________
______________________________ ______________________________
What is the primary language
spoken in the home?
English Spanish Other _____________________________________
What is the child’s dominant
language?
English Spanish Other _____________________________________
Are there other family members or
relatives who have or have had
any speech or language
therapy/issues?
No Yes If yes, who and what kind of issues?
BIRTH HISTORY
Was there anything remarkable
about mother’s health during
pregnancy or delivery?
No Yes If yes, explain:
Was there anything remarkable
about your child’s condition at
birth?
No Yes If yes, explain:
Does your child have
developmental concerns other
than the speech/language
problem?
No Yes If yes, explain:
Were there any illnesses or
complications during pregnancy
with this child?
No Yes If yes, explain:
Pregnancy term and birth weight:
No If no, how many weeks? ________ Birth Weight ________
Delivery Method:
Were there any drugs or
medications taken before or
during this pregnancy? (i.e. invitro
therapy, antidepressants, etc.)
No Yes If yes, explain:
Were there any immediate
problems following birth or
during the first 2 months of the
infant’s life?
No Jaundice Surgery Feeding Required Oxygen Illness
Sucking or swallowing problems Sleep patterns Other: ____________
Explain:
Page 5 of 14
MEDICAL HISTORY
How is your child’s overall health?
Good Fair Poor
Are immunizations up to date?
Yes No
Does your child have any known
allergies?
None Yes If yes, please list:
List all medications and dosages
currently prescribed for the child:
MEDICATION
DOSAGE
PURPOSE
Does your child have a history of
surgery/hospitalization?
No Yes If yes, please explain:
Please check the following as they apply
to your child: Please provide any
necessary documentation of diagnoses
prior to evaluation date
Autism
ADHD/ADD
Down Syndrome ODD
Cerebral Palsy Birth Defects
Dyslexia Hearing Loss
Learning Disability None
Psychological/Behavioral Issues Other ________________________
Has your child had any of the following
conditions?
Asthma Head Injury Gastric Reflux
Tonsillitis/Tonsillectomy Nerve Injury Low Birth Weight
Pneumonia Diabetes Cleft Lip
Adenoidectomy Seizure Disorder Cleft Palate
Food Sensitivities Visual Impairments Other ___________
Spinal Cord Injury Juvenile Arthritis
How would you characterize your child’s
diet?
Regular- All foods allowed: no known food allergies or dietary restrictions
Regular- With exceptions: List food allergies/dietary restrictions:
__________________________________________________________
Liquids
Pureed (requiring very little chewing ability)
Mechanical Altered (requiring some chewing)
Advanced (soft food that require more chewing ability)
G-Tube
At what age did your child do the
following:
Sit ________ Crawl_________ Stand________ Walk_________
Use w
ords_________ Combine words__________
Please describe any other relevant
medical diagnosis or concerns?
N/A Yes If yes, please list:
Page 6 of 14
BEHAVIORAL BACKGROUND
Please check all that apply to your
child:
Yells/screams frequently
YES NO
Friendly/outgoing
Is usually happy
Is frustrated easily
Poor turn taking skills
Poor eye contact
Sleeping difficulties
Attentive
Cooperative
Eating difficulties
Destructive/aggressive
Thumb/finger sucking habit
Exhibits difficulty learning new tasks
Imitates actions/speech
Difficulty with transitions/resistant to change
Difficulty separating from parent
Self-stimulation/self-injury
Plays with toys appropriately
Understands praise/punishment
Plays alone for reasonable amount of time
Mostly quiet
Poor memory
Impulsive/restless
Difficulty concentrating
Lacks pretend play
Avoids group play
Recognizes danger
Avoids eye contact
Withdrawn
Overly active
How often do the following behaviors occur? (O = Often, S = Sometimes, N = Never)
Inattentiveness
Sensitivity
Perfectionism
Competitiveness
Lack of confidence
Excessive shyness
Strong fears
Frustration
Excessive neatness
Excitability
Hyperactivity
Nervousness
Page 7 of 14
EDUCATIONAL BACKGROUND
Age at entrance to school:
________years ________months
If not of school age you may skip
this section.
Current School: ________________________________________________________
Grade__________________ Grades repeated, if any_________________________
Type of classroom:
General Education Special Education Gifted/Talented
Does your child have an IFSP or
IEP?
No Yes If yes, please provide recent report prior to or at time of evaluation.
Indicate any/all areas of
difficulties
Reading Math Spelling Handwriting Writing sentences
Social skills/Interacting with others
SPEECH/LANGUAGE HISTORY
How does your child communicate
his/her wants and needs:
Looking at objects Complete sentences Pulling you to wants/needs
Sounds/Grunting Conversations Physically seeking
Pointing/Gestures Picture Symbols, PECS
Single words Augmentative/Alternative Communication Device
2-4 Word phrases
Sign Language
Which of the following best
describes your child’s speech:
Please check all that apply
Too young to talk
Does not use words
Gestures more than words
Easy to understand
Difficult for family to understand
Difficult for others to understand
How much of your child’s speech
do you understand?
0% 10% 25% 50% 75% 100%
Does speech improve with repetition? Yes No
Estimate how many words are in
your child’s vocabulary:
Expressive (Speaking Vocabulary): Under 25 25-75 Over 75
Receptive (Understanding vocabulary): Under 25 25-75 Over 75
Does your child have difficulties
with any of the following?
Please check all that apply
Pronouncing a variety of sounds (articulation)
Speaking fluently (stuttering)
Voice complaints e.g.: hoarse, breathy, effortful, strained
Written language concerns (reading, writing & spelling)
Understanding what you are saying
Expressing thoughts/Making requests or needs known
Following simple directions (“Get your shoes” or “Close the door”)
Recognizing/pointing to common objects
Answering yes/no questions
Answering who/what/where/when/why questions
Does your child do any of the
following?
Please check all that apply
Repeat sounds, words or phrases over and over
Need directions repeated often
Have difficulty getting along with peers
Prefers to play alone
Have a hard time making connections with familiar people
Function best in a small group or individually
Wander aimlessly without purposeful play or explorations
Play with same toy for hours
Engage in meaningful conversation or communicate with intent
Page 8 of 14
SPEECH/LANGUAGE HISTORY CONT.
Did your child meet developmental
milestones age appropriately?
Ba
bble/Coo by 6 months
Respond to name by 8 months
Peek-a-Boo by 8 months
Imitate sounds by 12 months
Use jargon by 12 months
Say first words by 15 months
Combine 2 words by 2 years
Use short sentences by 3 years
Use simple questions
Engage in conversation
Yes
No If no, age in months___________________ N/A
Yes No If no, age in months___________________ N/A
Yes No If no, age in months___________________ N/A
Yes No If no, age in months___________________ N/A
Yes No If no, age in months___________________ N/A
Yes No If no, age in months___________________ N/A
Yes No If no, age in months___________________ N/A
Yes No If no, age in months___________________ N/A
Yes No If no, age in months___________________ N/A
Yes No If no, age in months___________________ N/A
Have other family members had
speech/language problems?
Yes No If yes, please indicate the person’s relationship to the child
and nature of problem:
Has your child previously been assessed
for speech/language concerns?
Yes No If yes, please provide all documentation of previous testing
prior to evaluation or at time of your visit.
Has your child received any prior
speech/language therapy?
Yes No If so: Where? ______________________________________
By whom? __________________ Duration of treatment? _______________
Focus of treatment?
Results of treatment/Satisfaction:
HEARING
Has the patient’s hearing ever been
tested?
No Yes If yes, Where? When? By Whom? What were the
results/recommendation?
How many ear infections has your child
had?
None
1-2
3-5
6-10
10 or more
Has your child worn Pressure
Equalization tubes (PE Tubes)?
No Yes Which ear(s): ________________ How long? ____________
Does your child have a diagnosed hearing
impairment? Please provide any
appropriate reports prior to evaluation or
at time of your visit.
No Yes If yes, Where? When: By Whom? Is the loss in one or both
ears? What is the level of loss?
Does your child wear hearing aids?
No Yes If yes, which ear(s) are the aids worn?
Page 9 of 14
SPEECH FLUENCY AND STUTTERING
Do you have concerns about your child’s
fluency or notice your child stuttering?
Yes No If no, please skip this section.
Rate how often your child is able to speak
fluently in the following situations:
At Home
At School
In New Situations
Always
Always
Always
Almost Always
Almost Always
Almost Always
Sometimes
Sometimes
Sometimes
Rarely
Rarely
Rarely
Never
Never
Never
When did your child first start stuttering?
(Be as specific as possible)
Age_____________ When is stuttering more frequent?
Is the child aware of disfluencies No Yes
What did the stuttering sound like when
it first began?
Describe how your child’s fluency
sounds now:
What seems to help your child when
he/she is stuttering?
Has your child ever demonstrated any of
the following:
Physical tension during stuttering
Awareness of stuttering
Frustration about speaking Complaints that he/she can’t talk
Describe:
How does the child’s stuttering affect his
or her:
Academic performance?
Participation in school activities?
Interaction with other children?
Interaction with family members?
Willingness to talk and communicate?
Self-esteem or attitude toward self?
Describe below:
__________
____________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
Has your child ever been teased about
stuttering?
No Yes If yes, please describe
Has your child ever discussed his/her
speaking difficulties with you?
No Yes If yes, please describe
Page 10 of 14
FEEDING
Do you have concerns about your
child’s eating?
Is your child a picky eater?
Yes No
Yes No If you answered no to both of the following questions,
please skip this section.
Does your child have a history of the
following? Check all that apply
Aspiration Pneumonia Reflux Coughing Choking Gagging
Has your child ever had difficulty
chewing or swallowing? Do they spit
out food? Please explain
Do you feel your child is eating enough
and/or meeting their nutritional needs?
Yes No If no, please explain
Do you eat as a family at a table?
If
not, where does your child eat their
meals? Please explain
Yes
No
How long does the meal usually last in
the following setting?
At home: _________________________________________________
At school: _________________________________________________
At a restaurant: _________________________________________________
What is your child’s typical diet for the
following meals?
Please list specific foods or types of
foods, if possible.
Breakfast
Lunch
Dinner
Does your child try new foods?
Ha
s your child recently added new
foods to their diet?
Yes No
Yes No If so, please list/describe
Page 11 of 14
Feedings Cont.
Does your child eat a variety of foods?
Check all that apply
Grains Fruits Vegetables Meat
List preferred foods:
Does your child eat a variety of
textures?
Check all that apply
Soft Hard Crunchy Cold Hot
Which textures are preferred?
Has your child been losing weight?
Yes No If yes, what is your child’s current weight _______________
Does your child have any food
allergies?
Yes No If yes, please list
Does your child have diet modifications
due to allergies/other reason?
Yes No If yes, please describe
How would you like mealtime to
change?
Ideally, how long would you like for
each meal to take to be completed?
If recommended, are you interested in
starting therapy to work on feeding
weaknesses?
Yes No
Page 12 of 14
VOICE
Do you or another health care
professional have concerns about your
child’s voice?
Yes No If no, please skip this section.
Describe your concerns:
Describe voice quality:
Check all that apply
Breathy Hoarse Rough Strained Nasal
Sounds like child has a cold
Onset of problem:
Has your child been seen by an ENT?
Yes No
If yes, when and who was your child seen by?
Does your child have any voice related
medical diagnosis? Please provide
documentation prior to evaluation.
Yes No If yes, please list:
Has there been an periods of child’s
“normal” voice since onset of problem?
Yes No If yes, please describe:
Is your child a singer/performer in
choir/theater?
Yes No If yes, how often does child practice/perform:
Describe daily use of child’s voice: (O= Often, S= Sometimes, N= Never)
Shouting/Yelling/Screaming
Singing
Loud Talking
Making noises/Impersonations
Talking over noise
Throat clearing/Coughing
Other:
Other:
Does your child have a history of?
Reflux
Asthma
Sleep Apnea
Allergies
If yes to any, list medications that
help with the items listed above:
Yes No If yes, at what age was child diagnosed ___________________
Yes No If yes, at what age was child diagnosed ___________________
Yes No If yes, at what age was child diagnosed ___________________
Yes No If yes, at what age was child diagnosed ___________________
Medications used for these:
Describe your child’s breathing:
Nasal Breather
Mouth Breather
Both
Unsure
Page 13 of 14
Voice Cont.
How many cups does your child
drink each day of the following:
Water __________ ounces/day
Juice __________ ounces/day
Caffeine/soda __________ ounces/day
Milk __________ ounces/day
Other __________ ounces/day
How many hours does your child
spend on the following:
Sleep _________________ Exercise _________________
Theater _________________ Choir _________________
Play Sports _________________
Does your child sleep with a
humidifier?
Yes No
Is your child exposed/sensitive to
strong smells/smoke: (perfumes,
second-hand smoke, etc.)
Yes No If yes, please describe:
Reminder: If any of the sections above asked that you provide documenta
tion, please provide prior to your
scheduled appointment. Our goal is to have as much information as possible and we appreciate you providing
the necessary information.
Person completing this form: ____________________________________________________________________________
Relationship to child: __________________________________________________________________________________
Print full name: _______________________________________________________________________________________
Signature: _______________________________________________ Date: ____________________________________
Thanks for choosing us for your therapy needs.
Page 14 of 14
Chesapeake Speech Language Associates, LLC
1419 Fo
rest Drive – Suite 206
Annapolis, MD 21403
410-280-9788
410-280-9790 (Fax)
Financial Policy and Agreement
1. Payment for services rendered by CSLA is due and payable in full at the time services are rendered, unless prior
arrangements have been made with the Practice Manager.
2. A $50 fee will be charged for any sessions canceled. If a make-up appointment is available and completed, the
cancellation fee may be waived. If a make-up session is not available, the cancellation fee will be charged. if there is
an available time to reschedule a missed appointment, we always prefer to see the patient for therapy. If you are not
able to accept that time or there is not one available, you will be charged for missing your appointment.
3. Payments: Unless other arrangements are approved by CLSA in writing, the balance on your statement is due
and
payable when the statement is issued and is past due if payment is not received within thirty (30) days.
4. Re-billing fee: A re-billing fee of $2 will be imposed on each account that is over thirty (30) days past due
5. Any balance unpaid after 60 days from the date services were rendered will be subject to interest at the annual
percentage rate of 18% with a $2.00 minimum.
6. Past due accounts: If your account becomes past due, we will take necessary steps to collect this debt. If we have to
refer your account to a collection agency and/or a lawyer, you agree to pay all of the collection costs that are
incurred, including lawyer’s fees and court costs, if applicable.
7. In the event the Patient submits payment by check and that check is returned for any reason by the Bank, CSLA will
add $25 to the balance owed by the Patient or Responsible Party.
8. For Patients with insurance: Any cost sharing, such as co-payments, coinsurance and/or deductibles are the
responsibility of the Patient or Responsible Party. In the event that services rendered are not covered, Patient or
Responsible Party shall be responsible for payment in full for those services.
9. Required payments: Any co-payments required by an insurance company must be paid at the time of service.
10. Insurance: Insurance is a contract between you and your insurance company. CSLA is NOT a party to this contract, in
most cases. CSLA will bill your insurance company as a courtesy to you. Although we may estimate what your
insurance might pay, it is the insurance company that makes the final determination. You agree to pay any portion of
the charges not covered by insurance. If your insurance company requires a referral and/or preauthorization, Patient
or Responsible Party is responsible for obtaining it. Failure to obtain the referral and/or preauthorization may result
in a lower or no payment from the insurance company.
11. No statement by an employee of CSLA will contradict, void, or nullify this Agreement, nor shall the Patient or
Responsible Party rely on any statements or opinions made by CSLA that the Patient’s insurance carrier will pay the
bill.
12. Waiver of confidentiality: You understand that if your account is submitted to an attorney and/or collection agency,
if CSLA has to litigate in court, or if your past due status is reported to a credit reporting agency, the fact that you
received treatment at CSLA will become a matter of public record.
By s
igned this agreement, you agree to all the terms and conditions contained herein. This agreement will take effect
from the date signed by the patient/parent/guardian/responsible party.
Pri
nt Name: ______________________________________________________________________________________
Sign
ature: _______________________________________________ Date: __________________________________
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1419 Forest Dr. Suite 206, Annapolis, MD 21403

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Completed 3 February 2021

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