Speech Forms

For the evaluation appointment scheduled please print and bring with you:  

1. The appropriate cover letter and review it for details 
2. The ONE correct case history form for your appointment type and complete fully 

Evaluation Cover Letter

• Communication evaluation appointments
• Feeding/swallowing evaluation appointments

Case History Forms
Children: 

• Feeding/swallowing case history form
• Speech resonance - cleft palate case history form
• Voice case history form

Adults: 

• Swallowing case history form
• Communication case history form
• Voice case history form
• Head and Neck Cancer swallowing/communication case history form

Additional Therapy Forms

• General Therapy agreement
• Pediatric feeding therapy - caregiver training agreement
• Understanding your insurance responsibilities