New patient intake form

This is the online version of the Talk Time new patient packet. Complete it and submit it securely — or print it and bring the signed copy to your first appointment.

Your form is sent over an encrypted connection and stored in a private, access-controlled record that only Talk Time staff can open. It is never shown publicly and is not emailed in plain text.

Client information

Child's full name

Date of birth

Home address

School / grade

Primary language(s) spoken at home

Parent / guardian information

Parent or guardian name

Relationship to child

Phone

Second parent / guardian (optional)

Emergency contact and phone

Client history

Share only what you are comfortable providing here. Anything sensitive can be discussed directly at the first appointment instead.

Reason for referral / current concerns

Birth and early developmental history

Relevant medical history, hearing or vision

Previous evaluations or therapy services

How your child currently communicates

Referred by (physician, school, other)

Pediatrician name and phone

Consents, agreement and permissions

These correspond to the forms in the new patient packet. Check each item you agree to; every checked item is signed on the printed copy.

New patient consent to the use and disclosure of health information for treatment, payment and health care operations.
Patient service agreement, including attendance, cancellation and payment responsibilities as reviewed with the office.
HIPAA authorization and acknowledgement of the Notice of Privacy Practices.
Authorization to release and obtain records related to my child's evaluation and therapy.
Permission to communicate with my child's school, physicians and other therapists.
Photo and video permission for therapy and documentation purposes (optional).

Signature

Parent / guardian name (typed)

Date