ComD Clinic Intake Forms

Please click on one of the links below to download the form you need as an editable PDF document. You will need Adobe Reader ® (download Adobe Reader free of charge) to fill out the form. Then complete the form on your computer, print it out, and mail it back to the clinic. The mailing address is:

Speech and Language Clinic
Department of Communication Disorders
Brigham Young University
1190 North 900 East
Provo, Utah 84602

All Clients

Services are provided on an equitable basis without regard to gender, sexual orientation, age, race, creed, national origin, or disability. Before receiving services at the clinic, clients are required to complete and sign the Authorization for Clinical Services. Click here for the Spanish Authorization form.

Adults

All adult clients need to complete the Adult Case History form. Click here for the Spanish Adult Case History form.  If you can provide additional information that is specific to your case, please use one of the other forms in addition to the Adult Case History form.

Children

Caregivers of children need to complete the Child Case History form. Click here for the Spanish Child Case History form.