Speech Therapy Client Intake Form

    Pediatric Case History























    Development Milestones

    At what age did your child begin to:










    Medical History Questions


    NormalComplications

    NormalComplications

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo






    Does your child attend an educational program?





    DDoes your child currently receive any therapy services?