Patient Name: *

First Name

Last Name

Patient DOB: *

MM

DD

YYYY

Patient Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Patient's Primary Physician *

First Name

Last Name

Patient's Primary Physician's Phone Number *

(###)

###

####

Guardian Name: *

First Name

Last Name

Phone: *

This phone number will be used to create a Klara account. Klara is our HIPAA compliant messaging app.

(###)

###

####

I am interested in receiving the following therapy services: *

Check all that apply:

Speech Therapy

Feeding Therapy

Occupational Therapy

I am unsure

Concerns for adult:

Select all that apply:

Speech/Communication

Cognition

Voice

Fluency

Dysphagia/Feeding

Accent Modificiation

Concerns for child

Select all that apply

Speech sounds

Grammar/Vocabulary/Sentence Length

Following directions

Fluency

Alternative communication or communication device

Swallowing

Chewing

Breast or bottle feeding

Tube feeding

Picky eating of varied textures/foods

Drinking from a cup

Tongue/Lip/Cheek tie

Feeding themselves

Weight gain

Reflux/GI issues

Vomiting while eating

Drooling

Fine motor skills

Self-care

Behavior

Strength, balance, coordination

Sensory difficulties

Check all that apply: *

The patient can follow 1-step directions.

The patient can sit at a table or sit in a high chair for 10 minutes.

The patient demonstrates challenges with dysregulation and/or behaviors of aggression.

The patient can communicate basic wants using words, gestures, or a communication device.

None of the above apply at this time.

Select any previous evaluations received: *

You will be asked to provide the selected evaluation reports. If therapy evaluation reports are less than one-year old, you may be able to begin therapy without an evaluation.

Speech therapy evaluation

Occupational therapy evaluation

Developmental/Neurological/Educational evaluation

None