New Client Information
 
 
 
 
 



 
 

Fields marked with * are mandatory
       
*Date:  
*First Name:  Middle Name:  Last Name:
Address:
Line 1
Line 2
City:  State:  Zip:
Telephone:   Home : - -     Work : - -
Date of Birth:      Age:     Sex:    
Marital Status:   Name of spouse or nearest relative:
Address (if different from yours):
Line 1
Line 2
City:  State:  Zip:
Social Security : # - -   Medicare/Medicaid : # - -
Referred by:
Educational level:   Occupation:
Employed by:
Address:
Line 1
Line 2
City:  State:  Zip:
List and describe all members of your present family living in your home, and any speech,
hearing or language problems present.

Name:
Relationship:
Communication problem:
YOUR CURRENT HEALTH STATUS: (Select Yes or No; Please explain more fully when appropriate)
Are you currently in good health?   Yes    No
Please explain:
Is your hearing good?  Yes    No
Please explain:
Is your vision good?  Yes    No
Please explain:
Are you ambulatory?  Yes    No
Please explain:
Are you currently taking medications?  Yes    No
If yes please list:
Do you have any associated medical pathology (e.g., cleft palate, cerebral palsy, post-CVA,
accident or injury) which may be contributing to your stuttering problem?  Yes    No
Please explain:
Have you been hospitalized within the past year? Yes    No
If so, may we contact your hospital for your discharge summary?


Name of hospital:
 
YOUR SPEECH, LANGUAGE OR HEARING PROBLEM:
Why are you seeking help at this time?
How long have you had this problem?


Have you been hospitalized within the past year?  Yes    No

If so, where?
For how long?
Describe the strategies that helped:
Describe those you tried that did not help:
What does your stuttering sound like to you?

Repeated sounds /words - Yes    No
Prolonged sounds - Yes    No
Holding breath - Yes    No
Sounds get stuck - Yes    No
When is the problem better?
When is it worse?
What do you think caused the problem?
How do you feel about the problem?
Do you avoid speaking at times? - Yes    No
Please explain:
What are the reactions of others to the problem?
Does the problem affect your job? - Yes    No
Does the problem affect school performance? - Yes    No
Please explain:
Does any member of your family have a similar problem?
In the space below, please provide any additional information that may be useful in evaluating
your communication and planning a treatment program:
 
                                                                                                        
Word Verification
Type the characters you see in the picture below:


Note : This information is confidential and intended only for use by Speech Pathways, P.C. personnel.
                                                                                                                                               
                                                                                                                                                          
                                                                                                                                                                                                                         
 
   

  
 

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