__________________________________________________________________
Language, Speech and Hearing Center
Department of Communication Disorders and Sciences
College of Health and Human Development
Adult Information Form
Thank you for your interest in our clinical services. To help us better serve you, please provide
us with the information requested below. Please be assured that this information will be held
confidential, and is necessary for the Center staff to determine appropriate evaluation and
therapy services. The completed form may be mailed or faxed to us at:
18111 Nordhoff Street
Monterey Hall, Room 100
Northridge, CA 91330-8288
818-677-2856; FAX 818-677-5952
E-mail: LSHC@csun.edu
Client Name: ______________________________
Date: _______________________
Date of Birth: ___/____/____
Sex:  M
Age: __________
F
Street Address: _________________________________________________________
City: ___________________
Phone Numbers:
State: _________
Home: _________________
Zip Code: __________________
Cell: ______________________
Work: __________________
E-mail: ______________________________________________________________________
Present Occupation: ___________________________________________________________
Highest Level of Education Completed: _____________________________________________
School Presently Attending, if applicable: ___________________________________________
Place of Birth: ________________________________________________________________
Native Language: _______________
Other Languages Spoken: __________________
How did you find out about this Center?______________________________________
Name of person filling out questionnaire: _____________________________________
Relationship to client, if other than client: _____________________________________
Services Requested:
 Speech-Language Evaluation
 Speech-Language Therapy
 Other ______________________________________
2
GENERAL INFORMATION
Describe the speech-language problem: ___________________________________________
____________________________________________________________________________
____________________________________________________________________________
What do you think may have caused the problem? ___________________________________
____________________________________________________________________________
____________________________________________________________________________
Has the problem changed since it was first noticed (e.g. improved or worsened)? ___________
____________________________________________________________________________
Have you had a previous speech-language evaluation?  Yes
 No
If yes, where and when? ___________________________________________________
If yes, what were the recommendations? _____________________________________
Have you had previous speech-language therapy?
 Yes
 No
Is yes, where and when? __________________________________________________
Have you seen any other specialists (physicians, audiologists, psychologists, neurologists, etc)?
 Yes
 No
If yes, indicate the type of specialist, when you were seen, and the specialist’s
conclusions or suggestions. ________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Medical History
Do you have or have you had any eating or swallowing difficulties?
 Yes
 No
 Yes
 No
 Yes
 No
If yes, please describe:
Do you have or have you had any problems with your breathing?
If yes, please describe:
Do you have or have you had any problems with vocal quality?
If yes, please describe:
Monterey Hall. 18111 Nordhoff Street. Northridge, CA 91330-8288.
(818) 677-2856 FAX (818) 677-5952
3
Please list any serious injuries, high fevers, seizures, hospitalizations, surgeries, neurological
events or diseases, physical handicaps, or other medical information that you think may be
relevant. Please give dates or approximate ages for each event.
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Are you presently under the care of a specialist (e.g. neurologist, an ear- nose- and throat
specialist (ENT), physiatrist (rehab M.D.), physical therapist, psychologist, or other? Yes  No
If yes, please list each specialist’s name, address, and type of specialty:
Please complete this chart regarding any medication that you are currently taking.
Medication
Dosage
Frequency of
Administration
Reason for Meds
Please describe any problems with your teeth, tongue, mouth, ears, nose, or throat:
___________________________________________________________________________
___________________________________________________________________________
Are you right- handed or left- handed? _____________________________________________
Monterey Hall. 18111 Nordhoff Street. Northridge, CA 91330-8288.
(818) 677-2856 FAX (818) 677-5952
4
Describe any vision or hearing problems you may have: _________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
FAMILY, SOCIAL AND EDUCATION INFORMATION
Do you have, or have you ever had, any school or learning problems? If so, please describe:
___________________________________________________________________________
Do you have, or have you ever had, problems with memory or thinking?
Yes  No
If yes, please describe:
Is there anything else you would like us to know? _____________________________________
____________________________________________________________________________
We thank you for your time, and the care with which you filled out this form. This intake form will
be reviewed by our professional licensed staff for appropriateness for this clinical setting, then
you will be contacted by our clinic office staff. While we strive to provide all requestors with the
therapy services that they desire, we would like you to keep two things in mind:

All clients, regardless of where they receive speech-language services, must have a
current speech and language assessment prior to the start of any therapy program.

We cannot make any promises about placement in therapy here in our Center until we
have completed our assessment process.
We appreciate your patronage, and look forward to helping you and your loved ones.
- The Professionals, Student Trainees, and Staff of the Language, Speech and Hearing Center
Monterey Hall. 18111 Nordhoff Street. Northridge, CA 91330-8288.
(818) 677-2856 FAX (818) 677-5952