mountstjoseph_New_Client

Mount St. Joseph University
Department of Speech, Language,
and Hearing Sciences
New Client Intake Questionnaire
Client Name:
Today's Date:
Date of Birth:
Age:
Form completed by:
Relationship to client:
1. Reason for Referral
What concerns led you to seek a speech, language, or swallowing evaluation/services at the MSJ Speech and Language clinic?
What are your primary goals for therapy?
2. Communication Concerns (check all that apply)
Other
How do these concerns affect daily life?
3. Medical History
Please list any significant medical conditions, diagnoses, surgeries, injuries, or hospitalizations:
Evaluations completed:
Current medications:
4. Previous Services
Previous therapy:
If yes, where and when?
Previous evaluations/reports available:
5. Daily Activities
Current setting:
Employed

Other
Primary language(s):
Communication supports Needed:

Other
6. Strengths & Interests
Strengths, interests, hobbies:
What motivates the client?
7. Additional Information
Is there anything else you would like us to know?
Should be Empty: