Clinic Intake Forms

Please right-click on the link to download the forms you need as a Microsoft Word document. 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.

Adults

All adult clients need to complete the 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.

• General
• Accent Reduction
• Aphasia
• Fluency
• Voice
• Hearing Impairment

Children

Caregivers of children need to complete the Child Case History form.