Intake Form

The following information is requested to help us to learn more about your child and your hopes for the evaluation process. The form covers many areas and can be completed in more than one sitting. If scheduled for an evaluation, you will also participate in a parent/caregiver interview where you can further discuss this information or share any additional information that you’d like us to know. The information you provide here will be stored securely in conjunction with HIPAA regulations. If you have any questions regarding this intake form or confidentiality, please contact us at (312) 399-0370.

Are you concerned about your child’s progress in speech and language development?

Contact Karen
Contact Karen & Chicago Speech Therapy

Are you concerned about your child’s progress in speech and language development?

Contact Karen
Contact Karen & Chicago Speech Therapy