McKay School of Education > Communication Disorders > Clinic Intake Forms
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 (available free of charge from www.adobe.com) 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.
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.
Children
Caregivers of children need to complete the Child Case History form.