Speech Intake Form

The following intake form is to be filled out by all speech therapy patients.  You are welcome to print the paper version of this form by choosing one of the versions below (it will take a few moments to load the printable version of the form). Then you may fill out the paper copy, and bring it with you to your first session. 

If you have any questions, feel free to contact CMH Rehab Services at (434) 447-0895.

Intake Form for Adults:
   Download the Word 2000 Version     
   Download the PDF Version

Intake Form for Children:
   Download the Word 2000 Version     
   Download the PDF Version

If you don't have access to Microsoft Word 2000 at home you can download the PDF file that can be viewed by Adobe Acrobat. If you do not have Adobe Acrobat, you may download it FREE here.