Client Information Form

MM slash DD slash YYYY
Client Name (required)(Required)
MM slash DD slash YYYY
Address (required)(Required)
City (required)(Required)
Occupation
Referred by
Physician Name
Physician Address
Marital Status
Spouse's Name

Speech, Language, Voice, Cognition, and Hearing History

Medical History

Provide the approximate ages at which you suffered the following illnesses and conditions and any relevant information:

Adenoidectomy
Asthma
Chicken Pox
Colds
Croup
Dizziness
Draining Ear
Ear Infections
Encephalitis
German measles
Headaches
Hearing loss
High fever
Influenza
Mastoiditis
Measles
Meningitis
Mumps
Noise exposure
Otosclerosis
Pneumonia
Seizures
Sinusitis
Tinnitus
Tonsillectomy
Tonsillitis
Vocal Problems
Other
Person completing form
Relationship to client
Signature: Type out name as your signature (required)(Required)
Accept Terms:(Required)

5 star ratingI love bringing my little one here. I've notice such a big difference in her speech. And Ms.Rachel is amazing... read more

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Bianca C.
1 month ago

My 2 year old son has been improving so much over the last few months & im very thankful for... read more

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Stephanie D.
7 months ago

Im beyond happy with the services my daughter is receiving. Her therapist Lupe has done an amazing job, from keeping... read more

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Ness M.
1 year ago
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