About this template
The Speech Therapy Assessment Google Form Template streamlines intake for speech-language pathologists, rehabilitation clinics, and pediatric practices. Designed to capture essential background data before an initial consultation, this form records patient demographics, primary communication concerns, medical history, language background, and prior speech therapy milestones.
Gathering comprehensive information prior to the first appointment allows clinicians to review developmental milestones, identify specific articulation or language delays, and prepare targeted evaluation materials. Standardizing your intake process reduces administrative friction and ensures you have all necessary clinical background stored securely in one organized place.
Key features
- Collect detailed speech history and primary communication goals in advance.
- Easily review patient medical history and current medications.
- Standardize clinical intake across schools, clinics, and private practices.
- Instantly organize responses for quick review before patient consultations.
Use cases
Initial intake evaluations for pediatric and adult speech-language pa…
Initial intake evaluations for pediatric and adult speech-language pathology practices.
Pre-screening documentation for school district speech therapy programs.
Remote telehealth intake for outpatient rehabilitation clinics.
What this form collects
- Full Name (Short answer)Enter the full name of the patient (or child if completing on behalf of a minor).
- Date of Birth (Date)Enter the patient's date of birth.
- Gender (Multiple choice)Select the patient's gender identity.
- Contact Number (Short answer)Provide a primary phone number for appointment reminders and updates.
- Email Address (Short answer)Provide a reliable email address for correspondence.
- Address (Paragraph)Enter the patient's current residential address.
- Reason for Seeking Speech Therapy (Paragraph)Describe your primary concerns regarding speech, language, swallowing, or communication.
- Speech and Language History (Paragraph)Describe any previous speech therapy evaluations, diagnoses, or treatment history.
- Medical History (Paragraph)List any relevant medical conditions, developmental history, hearing evaluations, or past surgeries.
- Current Medications (Paragraph)List any medications the patient is currently taking, or write 'None'.
- Speech and Language Skills (Paragraph)Summarize current strengths and challenges with articulation, fluency, voice, or understanding language.
- Language(s) Spoken (Short answer)List all languages spoken in the patient's home environment.
- Primary Language (Short answer)Specify the language primarily used for daily communication.
- Communication Devices Used (Paragraph)List any assistive communication devices, AAC apps, sign language, or visual aids currently utilized.
- Additional Comments (Paragraph)Share any other information you would like the therapist to know before your appointment.
FAQ
How can I share this assessment form with patients?
You can easily send the form link via email prior to the appointment or embed it directly on your practice website for new patients to complete.
Can I customize the questions on this template?
Yes. Once you convert or copy the template to your Google Forms account, you can add, remove, or edit any questions to match your clinical practice requirements.
Where are the submitted patient responses stored?
All responses are automatically collected in a secure Google Sheet linked to your form, making it easy to review data and track patient progress over time.
Can parents or guardians fill this out on behalf of a child?
Yes. The form questions are adaptable and can be completed by parents or caregivers detailing their child's speech and language background.
Get this form in your Google Drive
Save a copy to your Google Drive with one click (uses 1 credit). Or build from a PDF or description in the app.