Case History/Intake Form for Speech Therapy: FILLABLE (Pediatric)

Rated 5 out of 5, based on 3 reviews
3 Ratings
Communication Community
Grade Levels
PreK - 12th
Formats Included
  • PDF
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Communication Community

What educators are saying

Loved this resource for a case history form. Visually pleasing, thorough, and well planned out. My parents were able to fill out easily, but still provide plenty of information.


This 5-page FILLABLE PDF form is concise, well-designed, and perfect for sending
via Drive, Cloud, email, etc. to get fast parent/caregiver responses!

No more last-minute scrambling to get a student/client’s background information! 

This form was designed for thorough SLPs and SLPAs who work with school-aged/pediatric populations (i.e., birth - 22 years). Appropriate for school-based clinicians, clinicians in private practices, home care, early intervention, etc.

Can also be suitable for teachers or other related-service providers who are
concerned about their client’s speech and/or language.

Sections in this form:

  • Personal information
  • Home setting information
  • Medical & developmental history
  • Educational history
  • Speech and language information
  • Separate fillable page for additional comments
  • Thank you page


Communication Community, LLC is solely run and operated by two friends and passionate SLPs, Kristi and Becca. If you have enjoyed this product, we would truly appreciate your time to review!

Looking for additional FREE resources? Subscribe to our TpT store! We have shareable infographics, home/therapy resources, AND more!

We also release free weekly evidence-based content on our blog -

For more classroom/at-home resources and therapy ideas:

Instagram: @communicationcommunity

Facebook: @communicationcommunityslp


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